Benji K Mathews, MD, SFHM

Immigrant physicians and international medical graduates (IMGs) have for decades been very important to the healthcare delivery in the United States. For many currently serving on the front lines, the path has been full of challenges and uncertainties, now acutely worsened by the pandemic at hand. Manpreet Malik, MD, is one of those hospitalists. He grew up in a small city in India. He completed medical school in South India where he met students from all over the world and learned to speak a new language to serve local patients. The multicultural experience inspired him to pursue residency in the United States. Manpreet obtained a J-1 visa for residency and subsequently applied for a J-1 waiver for his first hospitalist job in 2013. Then his employer, a nonprofit organization, applied for H-1B and permanent resident status. He continues on an H-1B status but awaits his green card 7 years later. His wife, a dentist, is also an H-1B visa holder and they have two children. While they have assimilated into American society and flourished professionally, a sense of security eludes them. The COVID-19 pandemic has amplified this for their family. Like many other families, they are both in high-risk occupations and worry about the future, including what would happen if either or both of them contracted the virus. Their carefully planned life feels like a wobbly house of cards.

Immigrant healthcare workers are on the front lines in the fight against COVID-19 in the United States, accounting for 16.4% of healthcare workers amid this pandemic.¹ Of physicians in the United States, 29% are not born in the United States,and of the practicing hospitalists, 32% are IMGs.^1,2 IMGs are physicians who have graduated from medical schools outside of the United States and Canada who lack accreditation by the Liaison Committee on Medical Education.³ IMGs are a heterogeneous group with widely varying cultural, educational, and linguistic backgrounds with around 12,000 IMGs applying yearly for US residency positions.⁴ IMG hospitalists are uniquely positioned at the front lines facing arguably more risks with less recognition.⁵ The top five countries sending physicians to the United States are India, China, the Philippines, South Korea, and Pakistan.⁶ Yet many of these doctors—more than a third of those practicing in this country who graduated from international medical schools—have visa restrictions that limit their ability to work in communities with the greatest need.⁷ Another group of approximately 65,000 IMGs currently living in the United States are not licensed; they have not passed the board exam because they haven’t matched into a residency program to be eligible to take it.⁸ Many are working other jobs such as medical research, even though they could be deployed to serve as scribes or work in triage via telemedicine if their visas permitted.

During the COVID-19 pandemic, immigrant doctors are putting their lives on the line daily to care for patients. Immigrant doctors on visas are not eligible for Medicaid or Social Security benefits. Further, their partners and children are often dependent on them for legal resident status in the United States because of employer-based visa sponsorship. As the primary visa holder, if a non–US-born physician in the United States gets severely ill while fighting the virus, or gets disabled, they may have no benefits to fall back on. These physicians have houses, families, and children who are American citizens, and they are contributing members of society. Physicians on visas pay taxes the same way US citizens do. If their health or employment is jeopardized, their families would be unable to stay in the US legally, becoming undocumented and risking deportation. These physicians, who are fighting COVID-19 today, are helpless to provide a stable structure for their own loved ones.

With the COVID-19 pandemic unfolding, there is a risk of more physician shortages. The US healthcare workforce relies on immigrant physicians to help provide high-quality and accessible patient care. There are challenges for IMGs for getting into residency programs, and this limits the potential workforce during COVID-19. This year, according to the National Resident Matching Program, 4,222 non–US-born IMGs are due to start their US residency training on July 1.⁹ These doctors have the opportunity to serve across the country during this pandemic. According to data from the matching program, IMGs make up a large proportion of the workforce, obtaining 23% of the total number of US residency positions filled, and are in many leading academic institutions. These doctors, many of whom are waiting for their visas to be processed, need to be admitted in order to provide the care that Americans need during this pandemic. A similar number of IMGs will be completing their specialty training and are due to become attending physicians in their chosen field, including areas with critical shortages in this pandemic, such as critical care medicine. These skilled physicians depend on the processing of visa extensions or green cards in order to remain in the United States. Subspecialties like internal medicine and family medicine have a large proportion of actively practicing IMGs,⁷ and therefore provide primary care and inpatient care across the nation, especially in underserved areas. However, the geographic location of their practice is limited to the place that sponsored their visa. So a physician in rural Minnesota, where the outbreak of COVID-19 is not severe, cannot travel to hot spots such as New York or Detroit to provide care, even if they have a desire to serve.

For IMGs, the process of obtaining legal status in the US and pertinent immigration policies includes utilizing the H-1B visa program for highly skilled workers¹⁰ or J-1 visas for residencies.¹¹ H-1B visas are usually granted for sponsored positions in underserved or rural areas for at least 3 years, and the healthcare sector must compete with other industries, such as tech, engineering, and other specialty occupations. Physicians working on H-1B visas may apply for permanent work permits, though there is an annual cap for each country and candidates may wait decades to receive one. As a J-1 visa (cultural exchange program) holder, physicians are required to practice in their home country for 2 years prior to working again in the United States. This requirement could be waived by turning to the Conrad 30 Waiver Program¹² or J-1 waivers if they agreed to work in an underserved area in the United States. A limited number of J-1 waivers for each state are dispensed on a first-come, first-served basis (30 IMGs per state per year). This program currently is only authorized through the end of 2020, although legislation has been introduced to extend it, which could expand the slots.¹³ Applying for a J-1 waiver thus becomes a race against time with high-stakes suspense and anxiety for many IMGs. Most, regardless of visa status, dream of a stable and secure life, with permanent resident status as they serve their communities. For some, however, the endgame could mean deportation and the premature demise of dreams. 

Permanent resident status is allotted by country, and there is a long wait for green cards. Three-quarters of skilled workers waiting for green cards are from India. That translates to more than 700,000 people, of which approximately 200,000 are expected to die of old age before being granted green cards.^14,15 In the meantime, while they live with restrictions on both their employment and mobility, many physicians are doing essential medical work in underserved and rural areas throughout the United States.

We urge immigration reform to increase the physician workforce by providing immigrant doctors and IMGs with more flexibility to travel to areas where they are needed the most during this pandemic. There should be a blanket extension of visa deadlines. IMGs on J-1 student visas and H-1B specialty work visas should be exempt from any future immigration bans or limitations during the COVID-19 pandemic. The time is right for accelerating permanent resident status for these highly skilled IMGs. Green cards soon after finishing residency or fellowship training or satisfying a condition of initial visa approval should be the norm instead of a stressful unending wait. Clinicians who serve in underserved communities should be incentivized, and this should include health benefits. Restrictions related to primary and secondary work sites, as well as number of J-1 waivers, should also be relaxed. This flexibility would allow immigrant physicians to care at a variety of locations or by means of telemedicine.

A physician’s role is to heal and to serve their patients, regardless of their own origin. We are the voices of America’s immigrant physicians, particularly hospitalists, serving as frontline workers in our nation’s response to the COVID-19 crisis. The battle against COVID-19 has strained many of our resources, including the need for physicians. Uncertainty and chaos reign professionally and personally for many healthcare workers across America, and more challenges lie ahead for the foreseeable future. Healthcare workers are the unselfish and unwavering wall that stands between COVID-19 and more lives lost in our country. Every effort should be made to preserve and strengthen the healthcare workforce. Immigrant hospitalists, shackled by visa restrictions, could play an even bigger role if their obstacles were removed. It is time to provide them with the sense of security they deserve and rebuild the house of cards into something with a stronger foundation and more stability for our future.

Immigrant physicians and international medical graduates (IMGs) have for decades been very important to the healthcare delivery in the United States. For many currently serving on the front lines, the path has been full of challenges and uncertainties, now acutely worsened by the pandemic at hand. Manpreet Malik, MD, is one of those hospitalists. He grew up in a small city in India. He completed medical school in South India where he met students from all over the world and learned to speak a new language to serve local patients. The multicultural experience inspired him to pursue residency in the United States. Manpreet obtained a J-1 visa for residency and subsequently applied for a J-1 waiver for his first hospitalist job in 2013. Then his employer, a nonprofit organization, applied for H-1B and permanent resident status. He continues on an H-1B status but awaits his green card 7 years later. His wife, a dentist, is also an H-1B visa holder and they have two children. While they have assimilated into American society and flourished professionally, a sense of security eludes them. The COVID-19 pandemic has amplified this for their family. Like many other families, they are both in high-risk occupations and worry about the future, including what would happen if either or both of them contracted the virus. Their carefully planned life feels like a wobbly house of cards.

Immigrant healthcare workers are on the front lines in the fight against COVID-19 in the United States, accounting for 16.4% of healthcare workers amid this pandemic.¹ Of physicians in the United States, 29% are not born in the United States,and of the practicing hospitalists, 32% are IMGs.^1,2 IMGs are physicians who have graduated from medical schools outside of the United States and Canada who lack accreditation by the Liaison Committee on Medical Education.³ IMGs are a heterogeneous group with widely varying cultural, educational, and linguistic backgrounds with around 12,000 IMGs applying yearly for US residency positions.⁴ IMG hospitalists are uniquely positioned at the front lines facing arguably more risks with less recognition.⁵ The top five countries sending physicians to the United States are India, China, the Philippines, South Korea, and Pakistan.⁶ Yet many of these doctors—more than a third of those practicing in this country who graduated from international medical schools—have visa restrictions that limit their ability to work in communities with the greatest need.⁷ Another group of approximately 65,000 IMGs currently living in the United States are not licensed; they have not passed the board exam because they haven’t matched into a residency program to be eligible to take it.⁸ Many are working other jobs such as medical research, even though they could be deployed to serve as scribes or work in triage via telemedicine if their visas permitted.

During the COVID-19 pandemic, immigrant doctors are putting their lives on the line daily to care for patients. Immigrant doctors on visas are not eligible for Medicaid or Social Security benefits. Further, their partners and children are often dependent on them for legal resident status in the United States because of employer-based visa sponsorship. As the primary visa holder, if a non–US-born physician in the United States gets severely ill while fighting the virus, or gets disabled, they may have no benefits to fall back on. These physicians have houses, families, and children who are American citizens, and they are contributing members of society. Physicians on visas pay taxes the same way US citizens do. If their health or employment is jeopardized, their families would be unable to stay in the US legally, becoming undocumented and risking deportation. These physicians, who are fighting COVID-19 today, are helpless to provide a stable structure for their own loved ones.

With the COVID-19 pandemic unfolding, there is a risk of more physician shortages. The US healthcare workforce relies on immigrant physicians to help provide high-quality and accessible patient care. There are challenges for IMGs for getting into residency programs, and this limits the potential workforce during COVID-19. This year, according to the National Resident Matching Program, 4,222 non–US-born IMGs are due to start their US residency training on July 1.⁹ These doctors have the opportunity to serve across the country during this pandemic. According to data from the matching program, IMGs make up a large proportion of the workforce, obtaining 23% of the total number of US residency positions filled, and are in many leading academic institutions. These doctors, many of whom are waiting for their visas to be processed, need to be admitted in order to provide the care that Americans need during this pandemic. A similar number of IMGs will be completing their specialty training and are due to become attending physicians in their chosen field, including areas with critical shortages in this pandemic, such as critical care medicine. These skilled physicians depend on the processing of visa extensions or green cards in order to remain in the United States. Subspecialties like internal medicine and family medicine have a large proportion of actively practicing IMGs,⁷ and therefore provide primary care and inpatient care across the nation, especially in underserved areas. However, the geographic location of their practice is limited to the place that sponsored their visa. So a physician in rural Minnesota, where the outbreak of COVID-19 is not severe, cannot travel to hot spots such as New York or Detroit to provide care, even if they have a desire to serve.

For IMGs, the process of obtaining legal status in the US and pertinent immigration policies includes utilizing the H-1B visa program for highly skilled workers¹⁰ or J-1 visas for residencies.¹¹ H-1B visas are usually granted for sponsored positions in underserved or rural areas for at least 3 years, and the healthcare sector must compete with other industries, such as tech, engineering, and other specialty occupations. Physicians working on H-1B visas may apply for permanent work permits, though there is an annual cap for each country and candidates may wait decades to receive one. As a J-1 visa (cultural exchange program) holder, physicians are required to practice in their home country for 2 years prior to working again in the United States. This requirement could be waived by turning to the Conrad 30 Waiver Program¹² or J-1 waivers if they agreed to work in an underserved area in the United States. A limited number of J-1 waivers for each state are dispensed on a first-come, first-served basis (30 IMGs per state per year). This program currently is only authorized through the end of 2020, although legislation has been introduced to extend it, which could expand the slots.¹³ Applying for a J-1 waiver thus becomes a race against time with high-stakes suspense and anxiety for many IMGs. Most, regardless of visa status, dream of a stable and secure life, with permanent resident status as they serve their communities. For some, however, the endgame could mean deportation and the premature demise of dreams. 

Permanent resident status is allotted by country, and there is a long wait for green cards. Three-quarters of skilled workers waiting for green cards are from India. That translates to more than 700,000 people, of which approximately 200,000 are expected to die of old age before being granted green cards.^14,15 In the meantime, while they live with restrictions on both their employment and mobility, many physicians are doing essential medical work in underserved and rural areas throughout the United States.

We urge immigration reform to increase the physician workforce by providing immigrant doctors and IMGs with more flexibility to travel to areas where they are needed the most during this pandemic. There should be a blanket extension of visa deadlines. IMGs on J-1 student visas and H-1B specialty work visas should be exempt from any future immigration bans or limitations during the COVID-19 pandemic. The time is right for accelerating permanent resident status for these highly skilled IMGs. Green cards soon after finishing residency or fellowship training or satisfying a condition of initial visa approval should be the norm instead of a stressful unending wait. Clinicians who serve in underserved communities should be incentivized, and this should include health benefits. Restrictions related to primary and secondary work sites, as well as number of J-1 waivers, should also be relaxed. This flexibility would allow immigrant physicians to care at a variety of locations or by means of telemedicine.

A physician’s role is to heal and to serve their patients, regardless of their own origin. We are the voices of America’s immigrant physicians, particularly hospitalists, serving as frontline workers in our nation’s response to the COVID-19 crisis. The battle against COVID-19 has strained many of our resources, including the need for physicians. Uncertainty and chaos reign professionally and personally for many healthcare workers across America, and more challenges lie ahead for the foreseeable future. Healthcare workers are the unselfish and unwavering wall that stands between COVID-19 and more lives lost in our country. Every effort should be made to preserve and strengthen the healthcare workforce. Immigrant hospitalists, shackled by visa restrictions, could play an even bigger role if their obstacles were removed. It is time to provide them with the sense of security they deserve and rebuild the house of cards into something with a stronger foundation and more stability for our future.

Immigrant physicians and international medical graduates (IMGs) have for decades been very important to the healthcare delivery in the United States. For many currently serving on the front lines, the path has been full of challenges and uncertainties, now acutely worsened by the pandemic at hand. Manpreet Malik, MD, is one of those hospitalists. He grew up in a small city in India. He completed medical school in South India where he met students from all over the world and learned to speak a new language to serve local patients. The multicultural experience inspired him to pursue residency in the United States. Manpreet obtained a J-1 visa for residency and subsequently applied for a J-1 waiver for his first hospitalist job in 2013. Then his employer, a nonprofit organization, applied for H-1B and permanent resident status. He continues on an H-1B status but awaits his green card 7 years later. His wife, a dentist, is also an H-1B visa holder and they have two children. While they have assimilated into American society and flourished professionally, a sense of security eludes them. The COVID-19 pandemic has amplified this for their family. Like many other families, they are both in high-risk occupations and worry about the future, including what would happen if either or both of them contracted the virus. Their carefully planned life feels like a wobbly house of cards.

Immigrant healthcare workers are on the front lines in the fight against COVID-19 in the United States, accounting for 16.4% of healthcare workers amid this pandemic.¹ Of physicians in the United States, 29% are not born in the United States,and of the practicing hospitalists, 32% are IMGs.^1,2 IMGs are physicians who have graduated from medical schools outside of the United States and Canada who lack accreditation by the Liaison Committee on Medical Education.³ IMGs are a heterogeneous group with widely varying cultural, educational, and linguistic backgrounds with around 12,000 IMGs applying yearly for US residency positions.⁴ IMG hospitalists are uniquely positioned at the front lines facing arguably more risks with less recognition.⁵ The top five countries sending physicians to the United States are India, China, the Philippines, South Korea, and Pakistan.⁶ Yet many of these doctors—more than a third of those practicing in this country who graduated from international medical schools—have visa restrictions that limit their ability to work in communities with the greatest need.⁷ Another group of approximately 65,000 IMGs currently living in the United States are not licensed; they have not passed the board exam because they haven’t matched into a residency program to be eligible to take it.⁸ Many are working other jobs such as medical research, even though they could be deployed to serve as scribes or work in triage via telemedicine if their visas permitted.

During the COVID-19 pandemic, immigrant doctors are putting their lives on the line daily to care for patients. Immigrant doctors on visas are not eligible for Medicaid or Social Security benefits. Further, their partners and children are often dependent on them for legal resident status in the United States because of employer-based visa sponsorship. As the primary visa holder, if a non–US-born physician in the United States gets severely ill while fighting the virus, or gets disabled, they may have no benefits to fall back on. These physicians have houses, families, and children who are American citizens, and they are contributing members of society. Physicians on visas pay taxes the same way US citizens do. If their health or employment is jeopardized, their families would be unable to stay in the US legally, becoming undocumented and risking deportation. These physicians, who are fighting COVID-19 today, are helpless to provide a stable structure for their own loved ones.

With the COVID-19 pandemic unfolding, there is a risk of more physician shortages. The US healthcare workforce relies on immigrant physicians to help provide high-quality and accessible patient care. There are challenges for IMGs for getting into residency programs, and this limits the potential workforce during COVID-19. This year, according to the National Resident Matching Program, 4,222 non–US-born IMGs are due to start their US residency training on July 1.⁹ These doctors have the opportunity to serve across the country during this pandemic. According to data from the matching program, IMGs make up a large proportion of the workforce, obtaining 23% of the total number of US residency positions filled, and are in many leading academic institutions. These doctors, many of whom are waiting for their visas to be processed, need to be admitted in order to provide the care that Americans need during this pandemic. A similar number of IMGs will be completing their specialty training and are due to become attending physicians in their chosen field, including areas with critical shortages in this pandemic, such as critical care medicine. These skilled physicians depend on the processing of visa extensions or green cards in order to remain in the United States. Subspecialties like internal medicine and family medicine have a large proportion of actively practicing IMGs,⁷ and therefore provide primary care and inpatient care across the nation, especially in underserved areas. However, the geographic location of their practice is limited to the place that sponsored their visa. So a physician in rural Minnesota, where the outbreak of COVID-19 is not severe, cannot travel to hot spots such as New York or Detroit to provide care, even if they have a desire to serve.

For IMGs, the process of obtaining legal status in the US and pertinent immigration policies includes utilizing the H-1B visa program for highly skilled workers¹⁰ or J-1 visas for residencies.¹¹ H-1B visas are usually granted for sponsored positions in underserved or rural areas for at least 3 years, and the healthcare sector must compete with other industries, such as tech, engineering, and other specialty occupations. Physicians working on H-1B visas may apply for permanent work permits, though there is an annual cap for each country and candidates may wait decades to receive one. As a J-1 visa (cultural exchange program) holder, physicians are required to practice in their home country for 2 years prior to working again in the United States. This requirement could be waived by turning to the Conrad 30 Waiver Program¹² or J-1 waivers if they agreed to work in an underserved area in the United States. A limited number of J-1 waivers for each state are dispensed on a first-come, first-served basis (30 IMGs per state per year). This program currently is only authorized through the end of 2020, although legislation has been introduced to extend it, which could expand the slots.¹³ Applying for a J-1 waiver thus becomes a race against time with high-stakes suspense and anxiety for many IMGs. Most, regardless of visa status, dream of a stable and secure life, with permanent resident status as they serve their communities. For some, however, the endgame could mean deportation and the premature demise of dreams. 

Permanent resident status is allotted by country, and there is a long wait for green cards. Three-quarters of skilled workers waiting for green cards are from India. That translates to more than 700,000 people, of which approximately 200,000 are expected to die of old age before being granted green cards.^14,15 In the meantime, while they live with restrictions on both their employment and mobility, many physicians are doing essential medical work in underserved and rural areas throughout the United States.

We urge immigration reform to increase the physician workforce by providing immigrant doctors and IMGs with more flexibility to travel to areas where they are needed the most during this pandemic. There should be a blanket extension of visa deadlines. IMGs on J-1 student visas and H-1B specialty work visas should be exempt from any future immigration bans or limitations during the COVID-19 pandemic. The time is right for accelerating permanent resident status for these highly skilled IMGs. Green cards soon after finishing residency or fellowship training or satisfying a condition of initial visa approval should be the norm instead of a stressful unending wait. Clinicians who serve in underserved communities should be incentivized, and this should include health benefits. Restrictions related to primary and secondary work sites, as well as number of J-1 waivers, should also be relaxed. This flexibility would allow immigrant physicians to care at a variety of locations or by means of telemedicine.

A physician’s role is to heal and to serve their patients, regardless of their own origin. We are the voices of America’s immigrant physicians, particularly hospitalists, serving as frontline workers in our nation’s response to the COVID-19 crisis. The battle against COVID-19 has strained many of our resources, including the need for physicians. Uncertainty and chaos reign professionally and personally for many healthcare workers across America, and more challenges lie ahead for the foreseeable future. Healthcare workers are the unselfish and unwavering wall that stands between COVID-19 and more lives lost in our country. Every effort should be made to preserve and strengthen the healthcare workforce. Immigrant hospitalists, shackled by visa restrictions, could play an even bigger role if their obstacles were removed. It is time to provide them with the sense of security they deserve and rebuild the house of cards into something with a stronger foundation and more stability for our future.

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, was declared a pandemic on March 11, 2020. Although most patients (81%) develop mild illness, 14% develop severe illness, and 5% develop critical illness, including acute respiratory failure, septic shock, and multiorgan dysfunction.¹

Point-of-care ultrasound (POCUS), or bedside ultrasound performed by a clinician caring for the patient, is being used to support the diagnosis and serially monitor patients with COVID-19. We performed a literature search of electronically discoverable peer-reviewed publications on POCUS use in COVID-19 from December 1, 2019, to April 10, 2020. We review key POCUS applications that are most relevant to frontline providers in the care of COVID-19 patients.

Diagnosing COVID-19 disease by polymerase chain reaction is limited by availability of testing, delays in test positivity (mean 5.1 days), and high false-negative rate early in the course of the disease (sensitivity 81%).² Chest computed tomography (CT) scans are often requested during the initial evaluation of suspected COVID-19, but the American College of Radiology has recommend against the routine use of CT scans for diagnosing COVID-19.³

The diagnostic accuracy of lung ultrasound (LUS) has been shown to be similar to chest CT scans in patients presenting with respiratory complaints, such as dyspnea and hypoxemia, caused by non–COVID-19 pneumonia (sensitivity, 85%; specificity, 93%).⁴ Normal LUS findings correlate well with CT chest scans showing absence of typical ground glass opacities. This negative predictive value is very important.⁵ However, early in the course of COVID-19, similar to CT scans, LUS may be normal during the first 5 days or in patients with mild disease.² Unique advantages of LUS in COVID-19 include immediate availability of results, repeatability over time, and performance at the bedside, which avoids transportation of patients to radiology suites and disinfection of large imaging equipment.

LUS findings in COVID-19 include (a) an irregular, thickened pleural line, (b) B-lines in various patterns (discrete and confluent), (c) small subpleural consolidations, and (d) absence of pleural effusions (Figure). Bilateral, multifocal disease is common, while lobar alveolar consolidation is less common.^6,7 In addition to supporting the initial diagnosis, LUS is being used to serially monitor hospitalized COVID-19 patients. As lung interstitial fluid content increases, discrete B-lines become confluent, and the number of affected lung zones increases, which can guide decisions about escalation of care. LUS is often used to guide decisions about prone ventilation, extracorporeal membrane oxygenation, and weaning from mechanical ventilation in acute respiratory failure of non–COVID-19 patients,⁸ and these concepts are being applied to COVID-19 patients. During recovery, reappearance of A-lines can be seen, but normalization of the LUS pattern is gradual over several weeks based on our experience and one report.⁹ Multiple LUS protocols examining 6 to 12 lung zones have been published prior to the COVID-19 pandemic. We recommend continuing to use an institutional protocol and evaluating at least one to two rib interspaces on the anterior, lateral, and posterior chest wall.

Myriad cardiac complications have been described in COVID-19 – including acute coronary syndrome, myocarditis, cardiomyopathy with heart failure, and arrhythmias – secondary to increased cardiac stress from hypoxia, direct myocardial infection, or indirect injury from a hyperinflammatory response. Mortality is higher in patients with hypertension, diabetes, and coronary artery disease.^10,11 Cardiac POCUS is being used to evaluate COVID-19 patients when troponin and B-type natriuretic peptide (BNP) are elevated or when there are hemodynamic or electrocardiogram changes. Given the high incidence of venous thromboembolism (VTE) in COVID-19,¹² cardiac POCUS is being used to rapidly assess for right ventricular (RV) dysfunction and acute pulmonary hypertension.

The American Society of Echocardiography has recommended the use of cardiac POCUS by frontline providers for detection or characterization of preexisting cardiovascular disease, early identification of worsening cardiac function, serial monitoring and examination, and elucidation of cardiovascular pathologies associated with COVID-19.¹³ Sharing cardiac POCUS images in real time or through an image archive can reduce the need for consultative echocardiography, which ultimately reduces staff exposure, conserves personal protective equipment, and reduces need for decontamination of echocardiographic equipment.

The minimum cardiac POCUS views recommended in COVID-19 patients include the parasternal long-axis and short-axis views (midventricular level), either the apical or subcostal four-chamber view, and the subcostal long-axis view of the inferior vena cava.¹³ The goal of a cardiac POCUS exam is to qualitatively assess left ventricular (LV) systolic function, RV size and contractility, gross valvular and regional wall motion abnormalities, and pericardial effusion. In prone position ventilation, the swimmer’s position with one arm elevated above the shoulder may permit acquisition of apical views. Finally, integrated cardiopulmonary ultrasonography, including evaluation for deep vein thrombosis (DVT; see below), is ideal for proper characterization of underlying LV and RV function, volume status, and titration of vasopressor and inotropic support.

COVID-19 has been associated with a proinflammatory and hypercoagulable state with elevated d-dimer and higher-than-­expected incidence of VTE (27%) in critically ill patients.^12,14 Previous studies have demonstrated that frontline providers, including hospitalists, can detect lower extremity (LE) DVTs with high diagnostic accuracy using POCUS.¹⁵ Given the high incidence of DVTs despite prophylactic anticoagulation, some reports have suggested screening or serially monitoring for LE DVT in hospitalized COVID-19 patients.¹⁶ In patients with suspected pulmonary embolism (PE), POCUS can rapidly detect venous thrombosis that justifies prompt initiation of anticoagulation (eg, finding DVT or clot-in-transit), supportive findings of PE (eg, acute RV dysfunction, pulmonary infarcts), or alternative diagnoses (eg, bacterial pneumonia). However, it is important to recognize POCUS cannot definitively rule out PE. Additionally, subpleural consolidations are common in COVID-19 patients and could be caused by either infection or infarction. The American Society of Hematology has endorsed the use of POCUS, LE compression ultrasonography, and echocardiography in COVID-19 patients with suspected PE when availability of CT pulmonary angiography or ventilation-perfusion lung scans is limited.¹⁴

A POCUS exam for LE DVT consists of two-dimensional venous compression alone and yields results similar to formal vascular studies in both critically ill and noncritically ill patients. Because proximal LE thrombi have the highest risk of embolization, evaluation of the common femoral vein, femoral vein, and popliteal vein is most important.¹⁵ Either inability to compress a vein completely with wall-to-wall apposition or visualization of echogenic thrombus within the vein is diagnostic of DVT. Acute thrombi are gelatinous and may appear anechoic, while subacute or chronic thrombi are echogenic, but all veins with a DVT will not compress completely.

Ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase procedure success rates and decrease mechanical complications, primarily arterial puncture and pneumothorax. Similarly, higher success rates and fewer insertion attempts have been observed with ultrasound-guided peripheral intravenous line and arterial line placement.¹⁷ Ultrasound-­guided PIV placement can reduce referrals for midlines and peripherally inserted central catheters in hospitalized patients.¹⁸

In COVID-19 patients, use of ultrasound guidance for vascular access has distinct advantages. First, given the high incidence of DVT in COVID-19 patients,¹² POCUS allows preprocedural evaluation of the target vessel for thrombosis, as well as anatomic variations and stenosis. Second, visualizing the needle tip and guidewire within the target vein prior to dilation nearly eliminates the risk of arterial puncture and inadvertent arterial dilation, which is particularly important in COVID-19 patients receiving high-dose prophylactic or therapeutic anticoagulation. Third, when inserting internal jugular and subclavian CVCs, visualization of normal lung sliding before and after the procedure safely rules out pneumothorax. However, if lung sliding is not seen before the procedure, it cannot be used to rule out pneumothorax afterward. Additionally, visualizing absence of the catheter tip in the right atrium and presence of a rapid atrial swirl sign within 2 seconds of briskly injecting 10 mL of saline confirms catheter tip placement near the superior vena cava/right atrial junction, which can eliminate the need for a postprocedure chest radiograph.¹⁷

POCUS can be used to rapidly confirm endotracheal tube (ETT) placement, which can reduce reliance on postintubation chest radiographs. A meta-analysis of prospective and randomized trials showed transtracheal ultrasonography had high sensitivity (98.7%) and specificity (97.1%) for confirming tracheal placement of ETTs.¹⁹ Confirming endotracheal intubation involves two steps: First, a linear transducer is placed transversely over the suprasternal notch to visualize the ETT passing through the trachea, and not the esophagus, during insertion. Second, after the ETT cuff has been inflated, bilateral lung sliding should be seen in sync with the respiratory cycle if the ETT is in the trachea. Absent lung sliding, but preserved lung pulse, on the anterior hemithorax is likely caused by main stem bronchial intubation, and withdrawing the ETT until bilateral lung sliding is seen confirms tracheal placement. Additionally, the following steps are recommended to reduce the risk of exposure to healthcare workers: minimizing use of bag-valve-mask ventilation, performing rapid sequence intubation using video laryngoscopy, and connecting the ETT to the ventilator immediately.

Important considerations when selecting an ultrasound machine for use in COVID-19 patients include image quality, portability, functionality, and ease of disinfection. Advantages of handheld devices include portability and ease of disinfection, whereas cart-based systems generally have better image quality and functionality. To minimize the risk of cross contamination, an ultrasound machine should be dedicated exclusively for use on patients with confirmed COVID-19 and not shared with patients with suspected COVID-19.²⁰ To minimize exposure to COVID-19 patients, frontline providers should perform POCUS exams only when findings may change management, and timing of the exam and views acquired should be selected deliberately.

Ultrasound machine disinfection should be integrated into routine donning and doffing procedures. When possible, both handheld and cart-based machines should be draped with protective covers during aerosol-generating procedures. Single use ultrasound gel packets are recommended in order to decrease the risk of nosocomial infection.²⁰ After every use of an ultrasound machine on intact skin or for percutaneous procedures, low-level disinfection should be performed with an Environmental Protection Agency–recommended product that is effective against coronavirus.

Some ultrasound manufacturers have added teleultrasound software that allows remote training of novice POCUS users and remote guidance in actual patient care. Teleultrasound can be utilized to share images in real time with consultants or expert providers.

POCUS is uniquely poised to improve patient care during the COVID-19 pandemic. POCUS can be used to support the diagnosis of COVID-19 patients and monitor patients with confirmed disease. Common POCUS applications used in COVID-19 patients include evaluation of the lungs, heart, and deep veins, as well as performance of bedside procedures. Ultrasound machine portability and disinfection are important considerations in COVID-19 patients.

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, was declared a pandemic on March 11, 2020. Although most patients (81%) develop mild illness, 14% develop severe illness, and 5% develop critical illness, including acute respiratory failure, septic shock, and multiorgan dysfunction.¹

Point-of-care ultrasound (POCUS), or bedside ultrasound performed by a clinician caring for the patient, is being used to support the diagnosis and serially monitor patients with COVID-19. We performed a literature search of electronically discoverable peer-reviewed publications on POCUS use in COVID-19 from December 1, 2019, to April 10, 2020. We review key POCUS applications that are most relevant to frontline providers in the care of COVID-19 patients.

Diagnosing COVID-19 disease by polymerase chain reaction is limited by availability of testing, delays in test positivity (mean 5.1 days), and high false-negative rate early in the course of the disease (sensitivity 81%).² Chest computed tomography (CT) scans are often requested during the initial evaluation of suspected COVID-19, but the American College of Radiology has recommend against the routine use of CT scans for diagnosing COVID-19.³

The diagnostic accuracy of lung ultrasound (LUS) has been shown to be similar to chest CT scans in patients presenting with respiratory complaints, such as dyspnea and hypoxemia, caused by non–COVID-19 pneumonia (sensitivity, 85%; specificity, 93%).⁴ Normal LUS findings correlate well with CT chest scans showing absence of typical ground glass opacities. This negative predictive value is very important.⁵ However, early in the course of COVID-19, similar to CT scans, LUS may be normal during the first 5 days or in patients with mild disease.² Unique advantages of LUS in COVID-19 include immediate availability of results, repeatability over time, and performance at the bedside, which avoids transportation of patients to radiology suites and disinfection of large imaging equipment.

LUS findings in COVID-19 include (a) an irregular, thickened pleural line, (b) B-lines in various patterns (discrete and confluent), (c) small subpleural consolidations, and (d) absence of pleural effusions (Figure). Bilateral, multifocal disease is common, while lobar alveolar consolidation is less common.^6,7 In addition to supporting the initial diagnosis, LUS is being used to serially monitor hospitalized COVID-19 patients. As lung interstitial fluid content increases, discrete B-lines become confluent, and the number of affected lung zones increases, which can guide decisions about escalation of care. LUS is often used to guide decisions about prone ventilation, extracorporeal membrane oxygenation, and weaning from mechanical ventilation in acute respiratory failure of non–COVID-19 patients,⁸ and these concepts are being applied to COVID-19 patients. During recovery, reappearance of A-lines can be seen, but normalization of the LUS pattern is gradual over several weeks based on our experience and one report.⁹ Multiple LUS protocols examining 6 to 12 lung zones have been published prior to the COVID-19 pandemic. We recommend continuing to use an institutional protocol and evaluating at least one to two rib interspaces on the anterior, lateral, and posterior chest wall.

Myriad cardiac complications have been described in COVID-19 – including acute coronary syndrome, myocarditis, cardiomyopathy with heart failure, and arrhythmias – secondary to increased cardiac stress from hypoxia, direct myocardial infection, or indirect injury from a hyperinflammatory response. Mortality is higher in patients with hypertension, diabetes, and coronary artery disease.^10,11 Cardiac POCUS is being used to evaluate COVID-19 patients when troponin and B-type natriuretic peptide (BNP) are elevated or when there are hemodynamic or electrocardiogram changes. Given the high incidence of venous thromboembolism (VTE) in COVID-19,¹² cardiac POCUS is being used to rapidly assess for right ventricular (RV) dysfunction and acute pulmonary hypertension.

The American Society of Echocardiography has recommended the use of cardiac POCUS by frontline providers for detection or characterization of preexisting cardiovascular disease, early identification of worsening cardiac function, serial monitoring and examination, and elucidation of cardiovascular pathologies associated with COVID-19.¹³ Sharing cardiac POCUS images in real time or through an image archive can reduce the need for consultative echocardiography, which ultimately reduces staff exposure, conserves personal protective equipment, and reduces need for decontamination of echocardiographic equipment.

The minimum cardiac POCUS views recommended in COVID-19 patients include the parasternal long-axis and short-axis views (midventricular level), either the apical or subcostal four-chamber view, and the subcostal long-axis view of the inferior vena cava.¹³ The goal of a cardiac POCUS exam is to qualitatively assess left ventricular (LV) systolic function, RV size and contractility, gross valvular and regional wall motion abnormalities, and pericardial effusion. In prone position ventilation, the swimmer’s position with one arm elevated above the shoulder may permit acquisition of apical views. Finally, integrated cardiopulmonary ultrasonography, including evaluation for deep vein thrombosis (DVT; see below), is ideal for proper characterization of underlying LV and RV function, volume status, and titration of vasopressor and inotropic support.

COVID-19 has been associated with a proinflammatory and hypercoagulable state with elevated d-dimer and higher-than-­expected incidence of VTE (27%) in critically ill patients.^12,14 Previous studies have demonstrated that frontline providers, including hospitalists, can detect lower extremity (LE) DVTs with high diagnostic accuracy using POCUS.¹⁵ Given the high incidence of DVTs despite prophylactic anticoagulation, some reports have suggested screening or serially monitoring for LE DVT in hospitalized COVID-19 patients.¹⁶ In patients with suspected pulmonary embolism (PE), POCUS can rapidly detect venous thrombosis that justifies prompt initiation of anticoagulation (eg, finding DVT or clot-in-transit), supportive findings of PE (eg, acute RV dysfunction, pulmonary infarcts), or alternative diagnoses (eg, bacterial pneumonia). However, it is important to recognize POCUS cannot definitively rule out PE. Additionally, subpleural consolidations are common in COVID-19 patients and could be caused by either infection or infarction. The American Society of Hematology has endorsed the use of POCUS, LE compression ultrasonography, and echocardiography in COVID-19 patients with suspected PE when availability of CT pulmonary angiography or ventilation-perfusion lung scans is limited.¹⁴

A POCUS exam for LE DVT consists of two-dimensional venous compression alone and yields results similar to formal vascular studies in both critically ill and noncritically ill patients. Because proximal LE thrombi have the highest risk of embolization, evaluation of the common femoral vein, femoral vein, and popliteal vein is most important.¹⁵ Either inability to compress a vein completely with wall-to-wall apposition or visualization of echogenic thrombus within the vein is diagnostic of DVT. Acute thrombi are gelatinous and may appear anechoic, while subacute or chronic thrombi are echogenic, but all veins with a DVT will not compress completely.

Ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase procedure success rates and decrease mechanical complications, primarily arterial puncture and pneumothorax. Similarly, higher success rates and fewer insertion attempts have been observed with ultrasound-guided peripheral intravenous line and arterial line placement.¹⁷ Ultrasound-­guided PIV placement can reduce referrals for midlines and peripherally inserted central catheters in hospitalized patients.¹⁸

In COVID-19 patients, use of ultrasound guidance for vascular access has distinct advantages. First, given the high incidence of DVT in COVID-19 patients,¹² POCUS allows preprocedural evaluation of the target vessel for thrombosis, as well as anatomic variations and stenosis. Second, visualizing the needle tip and guidewire within the target vein prior to dilation nearly eliminates the risk of arterial puncture and inadvertent arterial dilation, which is particularly important in COVID-19 patients receiving high-dose prophylactic or therapeutic anticoagulation. Third, when inserting internal jugular and subclavian CVCs, visualization of normal lung sliding before and after the procedure safely rules out pneumothorax. However, if lung sliding is not seen before the procedure, it cannot be used to rule out pneumothorax afterward. Additionally, visualizing absence of the catheter tip in the right atrium and presence of a rapid atrial swirl sign within 2 seconds of briskly injecting 10 mL of saline confirms catheter tip placement near the superior vena cava/right atrial junction, which can eliminate the need for a postprocedure chest radiograph.¹⁷

POCUS can be used to rapidly confirm endotracheal tube (ETT) placement, which can reduce reliance on postintubation chest radiographs. A meta-analysis of prospective and randomized trials showed transtracheal ultrasonography had high sensitivity (98.7%) and specificity (97.1%) for confirming tracheal placement of ETTs.¹⁹ Confirming endotracheal intubation involves two steps: First, a linear transducer is placed transversely over the suprasternal notch to visualize the ETT passing through the trachea, and not the esophagus, during insertion. Second, after the ETT cuff has been inflated, bilateral lung sliding should be seen in sync with the respiratory cycle if the ETT is in the trachea. Absent lung sliding, but preserved lung pulse, on the anterior hemithorax is likely caused by main stem bronchial intubation, and withdrawing the ETT until bilateral lung sliding is seen confirms tracheal placement. Additionally, the following steps are recommended to reduce the risk of exposure to healthcare workers: minimizing use of bag-valve-mask ventilation, performing rapid sequence intubation using video laryngoscopy, and connecting the ETT to the ventilator immediately.

Important considerations when selecting an ultrasound machine for use in COVID-19 patients include image quality, portability, functionality, and ease of disinfection. Advantages of handheld devices include portability and ease of disinfection, whereas cart-based systems generally have better image quality and functionality. To minimize the risk of cross contamination, an ultrasound machine should be dedicated exclusively for use on patients with confirmed COVID-19 and not shared with patients with suspected COVID-19.²⁰ To minimize exposure to COVID-19 patients, frontline providers should perform POCUS exams only when findings may change management, and timing of the exam and views acquired should be selected deliberately.

Ultrasound machine disinfection should be integrated into routine donning and doffing procedures. When possible, both handheld and cart-based machines should be draped with protective covers during aerosol-generating procedures. Single use ultrasound gel packets are recommended in order to decrease the risk of nosocomial infection.²⁰ After every use of an ultrasound machine on intact skin or for percutaneous procedures, low-level disinfection should be performed with an Environmental Protection Agency–recommended product that is effective against coronavirus.

Some ultrasound manufacturers have added teleultrasound software that allows remote training of novice POCUS users and remote guidance in actual patient care. Teleultrasound can be utilized to share images in real time with consultants or expert providers.

POCUS is uniquely poised to improve patient care during the COVID-19 pandemic. POCUS can be used to support the diagnosis of COVID-19 patients and monitor patients with confirmed disease. Common POCUS applications used in COVID-19 patients include evaluation of the lungs, heart, and deep veins, as well as performance of bedside procedures. Ultrasound machine portability and disinfection are important considerations in COVID-19 patients.

COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, was declared a pandemic on March 11, 2020. Although most patients (81%) develop mild illness, 14% develop severe illness, and 5% develop critical illness, including acute respiratory failure, septic shock, and multiorgan dysfunction.¹

Point-of-care ultrasound (POCUS), or bedside ultrasound performed by a clinician caring for the patient, is being used to support the diagnosis and serially monitor patients with COVID-19. We performed a literature search of electronically discoverable peer-reviewed publications on POCUS use in COVID-19 from December 1, 2019, to April 10, 2020. We review key POCUS applications that are most relevant to frontline providers in the care of COVID-19 patients.

Diagnosing COVID-19 disease by polymerase chain reaction is limited by availability of testing, delays in test positivity (mean 5.1 days), and high false-negative rate early in the course of the disease (sensitivity 81%).² Chest computed tomography (CT) scans are often requested during the initial evaluation of suspected COVID-19, but the American College of Radiology has recommend against the routine use of CT scans for diagnosing COVID-19.³

The diagnostic accuracy of lung ultrasound (LUS) has been shown to be similar to chest CT scans in patients presenting with respiratory complaints, such as dyspnea and hypoxemia, caused by non–COVID-19 pneumonia (sensitivity, 85%; specificity, 93%).⁴ Normal LUS findings correlate well with CT chest scans showing absence of typical ground glass opacities. This negative predictive value is very important.⁵ However, early in the course of COVID-19, similar to CT scans, LUS may be normal during the first 5 days or in patients with mild disease.² Unique advantages of LUS in COVID-19 include immediate availability of results, repeatability over time, and performance at the bedside, which avoids transportation of patients to radiology suites and disinfection of large imaging equipment.

LUS findings in COVID-19 include (a) an irregular, thickened pleural line, (b) B-lines in various patterns (discrete and confluent), (c) small subpleural consolidations, and (d) absence of pleural effusions (Figure). Bilateral, multifocal disease is common, while lobar alveolar consolidation is less common.^6,7 In addition to supporting the initial diagnosis, LUS is being used to serially monitor hospitalized COVID-19 patients. As lung interstitial fluid content increases, discrete B-lines become confluent, and the number of affected lung zones increases, which can guide decisions about escalation of care. LUS is often used to guide decisions about prone ventilation, extracorporeal membrane oxygenation, and weaning from mechanical ventilation in acute respiratory failure of non–COVID-19 patients,⁸ and these concepts are being applied to COVID-19 patients. During recovery, reappearance of A-lines can be seen, but normalization of the LUS pattern is gradual over several weeks based on our experience and one report.⁹ Multiple LUS protocols examining 6 to 12 lung zones have been published prior to the COVID-19 pandemic. We recommend continuing to use an institutional protocol and evaluating at least one to two rib interspaces on the anterior, lateral, and posterior chest wall.

Myriad cardiac complications have been described in COVID-19 – including acute coronary syndrome, myocarditis, cardiomyopathy with heart failure, and arrhythmias – secondary to increased cardiac stress from hypoxia, direct myocardial infection, or indirect injury from a hyperinflammatory response. Mortality is higher in patients with hypertension, diabetes, and coronary artery disease.^10,11 Cardiac POCUS is being used to evaluate COVID-19 patients when troponin and B-type natriuretic peptide (BNP) are elevated or when there are hemodynamic or electrocardiogram changes. Given the high incidence of venous thromboembolism (VTE) in COVID-19,¹² cardiac POCUS is being used to rapidly assess for right ventricular (RV) dysfunction and acute pulmonary hypertension.

The American Society of Echocardiography has recommended the use of cardiac POCUS by frontline providers for detection or characterization of preexisting cardiovascular disease, early identification of worsening cardiac function, serial monitoring and examination, and elucidation of cardiovascular pathologies associated with COVID-19.¹³ Sharing cardiac POCUS images in real time or through an image archive can reduce the need for consultative echocardiography, which ultimately reduces staff exposure, conserves personal protective equipment, and reduces need for decontamination of echocardiographic equipment.

The minimum cardiac POCUS views recommended in COVID-19 patients include the parasternal long-axis and short-axis views (midventricular level), either the apical or subcostal four-chamber view, and the subcostal long-axis view of the inferior vena cava.¹³ The goal of a cardiac POCUS exam is to qualitatively assess left ventricular (LV) systolic function, RV size and contractility, gross valvular and regional wall motion abnormalities, and pericardial effusion. In prone position ventilation, the swimmer’s position with one arm elevated above the shoulder may permit acquisition of apical views. Finally, integrated cardiopulmonary ultrasonography, including evaluation for deep vein thrombosis (DVT; see below), is ideal for proper characterization of underlying LV and RV function, volume status, and titration of vasopressor and inotropic support.

COVID-19 has been associated with a proinflammatory and hypercoagulable state with elevated d-dimer and higher-than-­expected incidence of VTE (27%) in critically ill patients.^12,14 Previous studies have demonstrated that frontline providers, including hospitalists, can detect lower extremity (LE) DVTs with high diagnostic accuracy using POCUS.¹⁵ Given the high incidence of DVTs despite prophylactic anticoagulation, some reports have suggested screening or serially monitoring for LE DVT in hospitalized COVID-19 patients.¹⁶ In patients with suspected pulmonary embolism (PE), POCUS can rapidly detect venous thrombosis that justifies prompt initiation of anticoagulation (eg, finding DVT or clot-in-transit), supportive findings of PE (eg, acute RV dysfunction, pulmonary infarcts), or alternative diagnoses (eg, bacterial pneumonia). However, it is important to recognize POCUS cannot definitively rule out PE. Additionally, subpleural consolidations are common in COVID-19 patients and could be caused by either infection or infarction. The American Society of Hematology has endorsed the use of POCUS, LE compression ultrasonography, and echocardiography in COVID-19 patients with suspected PE when availability of CT pulmonary angiography or ventilation-perfusion lung scans is limited.¹⁴

A POCUS exam for LE DVT consists of two-dimensional venous compression alone and yields results similar to formal vascular studies in both critically ill and noncritically ill patients. Because proximal LE thrombi have the highest risk of embolization, evaluation of the common femoral vein, femoral vein, and popliteal vein is most important.¹⁵ Either inability to compress a vein completely with wall-to-wall apposition or visualization of echogenic thrombus within the vein is diagnostic of DVT. Acute thrombi are gelatinous and may appear anechoic, while subacute or chronic thrombi are echogenic, but all veins with a DVT will not compress completely.

Ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase procedure success rates and decrease mechanical complications, primarily arterial puncture and pneumothorax. Similarly, higher success rates and fewer insertion attempts have been observed with ultrasound-guided peripheral intravenous line and arterial line placement.¹⁷ Ultrasound-­guided PIV placement can reduce referrals for midlines and peripherally inserted central catheters in hospitalized patients.¹⁸

In COVID-19 patients, use of ultrasound guidance for vascular access has distinct advantages. First, given the high incidence of DVT in COVID-19 patients,¹² POCUS allows preprocedural evaluation of the target vessel for thrombosis, as well as anatomic variations and stenosis. Second, visualizing the needle tip and guidewire within the target vein prior to dilation nearly eliminates the risk of arterial puncture and inadvertent arterial dilation, which is particularly important in COVID-19 patients receiving high-dose prophylactic or therapeutic anticoagulation. Third, when inserting internal jugular and subclavian CVCs, visualization of normal lung sliding before and after the procedure safely rules out pneumothorax. However, if lung sliding is not seen before the procedure, it cannot be used to rule out pneumothorax afterward. Additionally, visualizing absence of the catheter tip in the right atrium and presence of a rapid atrial swirl sign within 2 seconds of briskly injecting 10 mL of saline confirms catheter tip placement near the superior vena cava/right atrial junction, which can eliminate the need for a postprocedure chest radiograph.¹⁷

POCUS can be used to rapidly confirm endotracheal tube (ETT) placement, which can reduce reliance on postintubation chest radiographs. A meta-analysis of prospective and randomized trials showed transtracheal ultrasonography had high sensitivity (98.7%) and specificity (97.1%) for confirming tracheal placement of ETTs.¹⁹ Confirming endotracheal intubation involves two steps: First, a linear transducer is placed transversely over the suprasternal notch to visualize the ETT passing through the trachea, and not the esophagus, during insertion. Second, after the ETT cuff has been inflated, bilateral lung sliding should be seen in sync with the respiratory cycle if the ETT is in the trachea. Absent lung sliding, but preserved lung pulse, on the anterior hemithorax is likely caused by main stem bronchial intubation, and withdrawing the ETT until bilateral lung sliding is seen confirms tracheal placement. Additionally, the following steps are recommended to reduce the risk of exposure to healthcare workers: minimizing use of bag-valve-mask ventilation, performing rapid sequence intubation using video laryngoscopy, and connecting the ETT to the ventilator immediately.

Important considerations when selecting an ultrasound machine for use in COVID-19 patients include image quality, portability, functionality, and ease of disinfection. Advantages of handheld devices include portability and ease of disinfection, whereas cart-based systems generally have better image quality and functionality. To minimize the risk of cross contamination, an ultrasound machine should be dedicated exclusively for use on patients with confirmed COVID-19 and not shared with patients with suspected COVID-19.²⁰ To minimize exposure to COVID-19 patients, frontline providers should perform POCUS exams only when findings may change management, and timing of the exam and views acquired should be selected deliberately.

Ultrasound machine disinfection should be integrated into routine donning and doffing procedures. When possible, both handheld and cart-based machines should be draped with protective covers during aerosol-generating procedures. Single use ultrasound gel packets are recommended in order to decrease the risk of nosocomial infection.²⁰ After every use of an ultrasound machine on intact skin or for percutaneous procedures, low-level disinfection should be performed with an Environmental Protection Agency–recommended product that is effective against coronavirus.

Some ultrasound manufacturers have added teleultrasound software that allows remote training of novice POCUS users and remote guidance in actual patient care. Teleultrasound can be utilized to share images in real time with consultants or expert providers.

POCUS is uniquely poised to improve patient care during the COVID-19 pandemic. POCUS can be used to support the diagnosis of COVID-19 patients and monitor patients with confirmed disease. Common POCUS applications used in COVID-19 patients include evaluation of the lungs, heart, and deep veins, as well as performance of bedside procedures. Ultrasound machine portability and disinfection are important considerations in COVID-19 patients.