SWOT analysis of prehospital ultrasound use and its practical implications

Abstract

This study aimed to assess the strengths, weaknesses, opportunities, and threats (SWOT) associated with prehospital ultrasound (US) use by paramedics and to explore its practical implications in emergency medical services. A structured, semiquantitative approach was employed, involving literature screening from 4 databases (PubMed, Scopus, Web of Science, and Medline) and synthesis via thematic content analysis, semiotic coding, and SWOT framework. Studies focusing on field use of US by paramedics were included. Predefined thematic indicators were applied to classify data into SWOT domains, and frequency analysis was used to identify prevailing patterns and trends. Among strengths, early diagnosis was most frequently reported (62.5%), followed by accurate intervention (25.0%) and diagnostic-guided treatment planning (12.5%). Weaknesses included limited training and experience (58.33%) and technical/device constraints (25.0%). Opportunities centered around digital education (54.17%) and emerging portable technologies (25.0%). Misdiagnosis (45.83%) and incomplete interventions (37.5%) were noted as key threats. Prehospital US performed by trained paramedics shows clear strengths in enabling early diagnosis and time-critical decision-making, but its scale-up is limited by insufficient longitudinal training/exposure and the absence of standardized implementation protocols. Opportunities include blended/digital education, tele-US supervision, and robust quality assurance and image archiving; the principal threat is misdiagnosis under real-world operational constraints, with downstream risks for triage and interventions. These findings support implementing structured, condition-specific longitudinal training, service-wide protocols with defined roles and maintenance accountability, and standardized equipment – priorities that future multicenter studies should link to patient-oriented outcomes.

1. Introduction

Prehospital care refers to emergency medical interventions provided to patients before they reach a hospital or healthcare facility.^[1] It plays a critical role in reducing mortality and morbidity, particularly in low- and middle-income countries where access to timely medical intervention remains limited and delays in hospital admission are common.^[2,3]

Prehospital care involves a diverse set of time-critical interventions aimed at stabilizing patients before hospital arrival. These interventions commonly address trauma, cardiovascular emergencies, and acute respiratory conditions.^[4–6] The development of trauma systems since the 1970s has led to a significant reduction in mortality, particularly by enabling rapid assessment and early intervention at the scene.^[4] As a result, prehospital care has emerged as a key focus in emergency medicine literature, with increasing attention given to its impact on early clinical decision-making, quality improvement initiatives, and the integration of simulation-based training for skill acquisition in field settings.^[7–9]

Point-of-care ultrasound (POCUS) has become an indispensable tool in emergency and trauma care, offering rapid, real-time imaging that supports timely clinical decision-making. It is frequently utilized in cardiac, abdominal, and shock-related assessments to evaluate volume status, cardiac function, and detect life-threatening conditions such as internal bleeding or pericardial effusion.^[10,11] With advances in technology, portable and user-friendly ultrasound (US) devices have expanded the scope of US use beyond hospital settings, allowing application in prehospital and remote environments.^[12] Despite these advancements, challenges such as operator dependency, variability in image acquisition, and limitations in device availability remain ongoing areas of investigation.^[13]

In recent years, the use of US by nonphysician prehospital providers – such as paramedics, nurses, and emergency medical technicians – has received increasing attention, particularly in the context of time-sensitive emergencies. This growing interest stems from the expanding scope of prehospital care and the availability of portable US devices. Evidence suggests that, with structured and competency-based training, nonphysician providers are capable of performing focused ultrasonographic assessments with clinically meaningful accuracy.^[14–16] However, the implementation of US by these professionals in the field continues to raise important questions regarding standardization, clinical autonomy, and integration into existing protocols.

While the literature broadly acknowledges the critical role of prehospital care in managing medical emergencies and consistently emphasizes the diagnostic utility of US across various clinical contexts, there remains no clear consensus regarding its implementation by nonphysician providers in prehospital settings.^{[2–9,11–13]} Existing studies are predominantly descriptive or narrative in nature, and few have adopted a structured, semiquantitative approach to evaluate its clinical effectiveness, cost-efficiency, or operational integration. This gap highlights the need for focused research to better understand the feasibility and impact of US when performed by prehospital providers.

To address this gap, the present study adopted a SWOT analysis as a strategic framework to systematically synthesize and categorize qualitative insights from the literature. This approach allows for the identification of practical leverage points by organizing complex clinical, operational, and educational dimensions surrounding prehospital US.

In light of this gap in the literature, the present study applies a structured SWOT analysis to examine the strengths, weaknesses, opportunities, and threats associated with US use by paramedics in the prehospital setting, and to explore its potential implications for real-world practice.

2. Materials and methods

2.1. Research model

This study employed a semiquantitative research design integrating content analysis, semiotic coding, and SWOT methodology to examine the literature on prehospital US use by paramedics. Through semiotic analysis, key themes and indicators were identified from qualitative sources and systematically transformed into quantifiable data. These indicators were then categorized under the 4 SWOT dimensions – strengths, weaknesses, opportunities, and threats – to allow for structured interpretation of trends across the selected studies. This approach was chosen to provide both a thematic and numerical understanding of the field.

2.2. Data set

Relevant literature on prehospital US use by paramedics was identified through a comprehensive search of Web of Science, PubMed, Scopus, and Medline databases. We searched PubMed, Scopus, Web of Science, and MEDLINE using the following terms: “prehospital ultrasound,” “paramedic ultrasound,” “prehospital POCUS,” and “emergency medical services ultrasound.” The time frame (January 2010–March 2024) was chosen to capture the modern era of portable/handheld US and the expanding literature on paramedic-performed prehospital US, while maintaining recency. Studies were selected based on their focus on nonphysician prehospital providers and their relevance to US use in prehospital emergency care. A total of 24 studies meeting the inclusion criteria were analyzed. To guide the SWOT categorization, a set of predefined thematic indicators was used. Indicators for strengths included: early diagnosis, accurate intervention, and appropriate treatment planning. Weaknesses were coded as: lack of knowledge or experience, equipment limitations, and technical insufficiencies. Opportunities involved digital learning tools, technological innovation, and triage optimization, while threats included misdiagnosis, incomplete or inappropriate interventions, and triage errors.

2.3. Data analysis

We transformed narrative data into structured findings in 3 steps: content analysis to identify recurring qualitative themes; semiotic coding to translate themes into quantifiable indicators; and categorization of each indicator into 1 of the 4 SWOT domains (strengths, weaknesses, opportunities, and threats), followed by simple frequency counts. Not all included studies contributed data to every domain; studies were analyzed only within the SWOT categories for which relevant data were present, and frequencies were computed accordingly. Illustrative mappings from study-level extracts to predefined indicators are provided in Table S1, Supplemental Digital Content, https://links.lww.com/MD/Q182.

Although the research is a semiquantitative analysis based on the SWOT methodology, a literature review was used to support quantitative data extraction. While the study does not qualify as a systematic review or meta-analysis, certain components of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews were partially followed to increase transparency and rigor in literature selection. Specifically, relevant indicators used in the SWOT framework – such as early diagnosis, technical inadequacy, digital education, and misdiagnosis – were predefined and studies were selected accordingly (Table 1).

Table 1.

SWOT categorization framework with predefined thematic indicators.

Strengths	Weakness	Opportunities	Threats
Early diagnosis	Insufficient knowledge-experience	Digital education	Misdiagnosis
Correct intervention	Technical inadequacy	Technologic innovations	Incomplete intervention
Correct diagnosis and treatment	Inadequate equipment	Correct triage	Triage errors

The indicators listed under each SWOT domain were determined prior to data extraction and used to guide the content and semiotic analysis of the selected studies. This categorization enabled a structured evaluation of the literature on prehospital USG by paramedics.

SWOT = strengths, weaknesses, opportunities, and threats, USG = ultrasonography.

Selection criteria included:

• –Relevance to predefined SWOT indicators.
• –Focus on paramedic-performed US.
• –Addressing prehospital scenarios involving nonphysician providers.
• –Inclusion of both conceptual and clinical studies.

2.4. Ethical considerations

This study did not require ethics committee approval as it was based on publicly available data and involved no human participants, identifiable personal data, or intervention. Therefore, Institutional Review Board approval and informed consent were not applicable. The study was conducted in accordance with the principles outlined in the Declaration of Helsinki.

3. Results

Findings are presented by SWOT domain. For each domain, we report indicator frequencies alongside representative extracts that illustrate the underlying themes identified across the included studies.

The 24 included studies were published between 2011 and 2024 and spanned multiple regions (e.g., Europe, North America, Australia, and Asia). Most were observational, pilot, or educational evaluation studies, with aims focused on diagnostic accuracy, feasibility and implementation, training effectiveness, and system integration of prehospital US. Although study scope and designs varied, all studies contributed thematic data to at least one SWOT domain.

3.1. Strengths of prehospital US

Among the identified strengths, early diagnosis emerged as the most frequently reported benefit of prehospital US use by paramedics, mentioned in 62.5% of studies.^[17–31] Several studies emphasized that early ultrasonographic assessment at the scene supports timely decision-making and facilitates prompt clinical intervention. The 2nd most cited strength was the ability to perform accurate, situation-specific interventions reported by 25.0% of studies.^[32–37] A smaller subset (12.5%) highlighted the value of integrating US findings into diagnostic reasoning and subsequent treatment planning^[38–40] (Fig. 1).

Figure 1.

Distribution of thematic indicators across SWOT categories in 24 included studies. This figure summarizes the frequency of thematic indicators identified across 24 studies and categorized into SWOT. USG and SWOT were the 2 primary constructs examined in the analysis. SWOT = strengths, weaknesses, opportunities, and threats, USG = ultrasonography.

3.2. Weaknesses of prehospital US

Weaknesses reported across the studies can be categorized into individual-level and system-level limitations. At the individual level, the most frequently cited issue was insufficient knowledge and limited hands-on experience among paramedics (58.33%).^{[17,21,24–29,31,33,35,36,38,40]}

System-level weaknesses were also commonly reported. Equipment-related limitations (16.67%) included not only device availability, but also adaptability to complex and unpredictable environments such as poorly lit or confined spaces.^{[19,23,34,37]} For example, studies by Chin et al and Schoeneck et al emphasized how certain prehospital settings hinder image acquisition or proper probe handling.^[19] Multiple studies reported real-world constraints – including environmental instability, device limitations/failures, and workflow pressures – that complicated consistent image acquisition and interpretation in the field.^{[15,18,22,35,39]}

Additionally, 25% of studies highlighted technical challenges such as poor image quality, probe instability, and interpretation under time pressure.^{[18,20,22,30,32,39]} (Fig. 1).

3.3. Opportunities for advancing prehospital US

The integration of digital education tools was the most frequently cited opportunity for enhancing prehospital US use, reported by 54.17% of the studies.^{[17,20,21,24,26–31,35,36,40]} Simulation-based modules, online certification programs, and mobile training platforms offer scalable and cost-effective ways to enhance US competency among prehospital providers. These platforms also enable flexible and continuous in-service learning, which is crucial in overcoming the knowledge and experience gap identified in this field.

Technological innovation was identified as an opportunity in 25.00% of the studies.^{[18,22,32,37–39]} The development of more portable, user-friendly, and AI-assisted US devices has the potential to reduce operator dependency and increase diagnostic confidence in challenging prehospital environments.

A total of 20.83% of the studies emphasized the role of prehospital US in improving triage decisions^{[19,23,25,33,34]} When used appropriately, prehospital US can help differentiate critical from noncritical conditions and ensure timely referral, thus contributing to more efficient patient flow within emergency care systems (Fig. 1).

3.4. Threats to effective prehospital US

The most frequently cited threat associated with prehospital US use by paramedics was the risk of misdiagnosis, reported in 45.83% of the studies.^{[20–22,24,27–31,38,39]} Limited training, suboptimal image acquisition, and high-pressure field environments can contribute to inaccurate interpretation, potentially leading to incorrect clinical assumptions.

A related concern, noted in 37.50% of the studies, was incomplete or inappropriate intervention resulting from suboptimal US assessments.^{[17,19,23,24,32,33,36,37,40]} These missteps may delay definitive care or result in avoidable complications.

Additionally, triage-related errors were mentioned in 16.67% of the studies, particularly when inaccurate US findings influenced prioritization or transport decisions.^{[18,25,34,35]} Misclassification of patient severity can disrupt emergency system flow, lead to over- or under-triage, and strain already limited healthcare resources (Fig. 1).

The distribution of key themes across SWOT dimensions is further illustrated in Figure 1, providing a synthesized visual overview of the findings presented above.

4. Discussion

This study aimed to synthesize evidence on paramedic-performed prehospital US using a semiquantitative SWOT framework, covering feasibility, diagnostic performance, and system integration.

Strengths centered on early diagnosis and contributions to time-sensitive decision-making; weaknesses clustered around limited longitudinal training/exposure and variable image quality; opportunities related to blended/digital education, tele-US, and quality assurance/archiving; and threats involved risks of misdiagnosis with downstream effects on triage or interventions under real-world operational constraints. Taken together, these findings highlight practical and educational gaps in current prehospital US practice.

Early diagnosis emerged as the dominant strength (>60% of included studies), underscoring the diagnostic value of prehospital US. Multiple studies showed that paramedics can obtain and interpret focused images that directly inform clinical decisions.^{[15,19,33,34,40]} Notably, Donovan et al found that 42% of US findings altered clinical impression or management; likewise, Chin et al reported high accuracy for pneumothorax and pericardial effusion following brief focused training.^[15,19] In undifferentiated dyspnea, Kowalczyk et al demonstrated rapid field application with high concordance to in-hospital diagnoses.^[33] Collectively, these data indicate that, when appropriately trained, paramedics can perform time-efficient, diagnostically meaningful evaluations that inform early decision-making and triage/destination planning in respiratory distress, trauma, and cardiac arrest.^[34,40]

Among the identified weaknesses, the most frequently cited issue was the lack of sufficient knowledge and supervised field experience (58.3% of the reviewed studies). Despite broader inclusion of POCUS in prehospital curricula, sustained exposure and supervised practice remain limited in many emergency medical services (EMS) settings, which likely constrains skill consolidation and interpretive confidence.^{[17,23,26,32,36]} In most of these, theoretical and practical limitations were discussed together, with limited opportunity to apply US in real-life field settings emphasized as a major barrier to skill retention and effective use.^[36,38] This aligns with multiple investigations showing that limited training and inadequate clinical exposure hinder paramedics’ ability to consistently acquire and interpret US images.^{[23,32,36,38,39]} For instance, Marsh-Feiley et al highlighted structural barriers to skill acquisition and integration, while Khalil et al found that even short-term education did not lead to statistically significant improvements in diagnostic accuracy.^[36,38] Collectively, these findings indicate that structured, longitudinal, and supervised training pathways – featuring recurrent practice, feedback, and competency checks – are required to sustain paramedics’ US proficiency under real-world conditions.

At the system level, the most salient weakness was the absence of standardized implementation protocols for prehospital US – spanning indications, target views/acquisition checklists, documentation and handover, quality assurance/archiving, and maintenance/operational accountability. In the absence of a unified framework, services reported inconsistent training syllabi, undefined operational roles and credentialing pathways, limited integration into routine decision-making and triage, and fragmented feedback mechanisms.^[22,30,32] Establishing clear, service-wide standard operating procedures and cross-agency standards is therefore essential for consistent and scalable implementation.^[22,30,32]

An important opportunity emerging from the analysis was the role of digital education in addressing training gaps and promoting broader US use in the prehospital setting. Over half of the reviewed studies highlighted the impact of structured training programs – particularly those incorporating blended or simulation-based methods – on paramedic competence and confidence.^{[17,23,26,32]} Roche et al demonstrated a statistically significant improvement in diagnostic accuracy and decision-making following focused US education, while Jonck et al showed that paramedics could perform at a level comparable to medical students after a structured blended curriculum.^[26,32] These findings suggest that targeted educational strategies have the potential to mitigate many of the knowledge-related weaknesses previously discussed. Digital and blended training programs were developed in diverse settings including university-affiliated EMS systems in Belgium, Australia, and the United States.^[26,28,32]

In addition to educational interventions, advancements in US technology and the integration of telemedicine were recognized as key enablers of prehospital US implementation.^[18,22,28] Studies such as that by Boniface et al confirmed that even untrained paramedics could acquire acceptable images under remote physician guidance, highlighting the transformative potential of real-time support and cloud-based systems.^[28] Furthermore, several studies indicated that US findings could improve triage decisions and influence destination planning in the field.^[19,25,37] The ability to make more informed triage decisions based on focused imaging adds a valuable layer to prehospital assessment, particularly in resource-limited or rural settings. The increasing availability of both basic and advanced US devices across EMS systems offers promising opportunities for wider US integration. While basic portable units enable broader access, advanced platforms with high-resolution imaging, wireless transmission, and remote supervision enhance diagnostic confidence.^{[18,28,29,32,37]} Studies have shown that with appropriate support, paramedics using either type of device can achieve clinically useful image quality and improve triage and treatment decisions in the prehospital setting.^{[28,32,37,39]}

The most frequently cited threat in the reviewed studies was misdiagnosis, reported in nearly half of the literature analyzed. Despite promising outcomes associated with prehospital US, multiple studies emphasized that limited experience and contextual complexity may result in diagnostic errors, particularly when image acquisition or interpretation is suboptimal.^{[18,24,27,39]}

Across the literature, contributing technical and operational constraints included device malfunction or poor transmission, low-resolution displays, battery/hardware failure, unstable probe–skin contact, motion artifacts during transport, and environmental/workflow pressures, each of which can degrade image quality and increase the risk of error.^[39] Moreover, specific responsibility for device maintenance and quality checks was rarely defined, which likely contributes to recurrent technical failures and inconsistent image quality.^[32,39] Consistent with these constraints, Becker et al found that a substantial proportion of scans were non-interpretable, and agreement between prehospital and emergency department diagnoses was moderate.^[39] Similarly, Fitzgerald et al highlighted that despite improved diagnostic confidence after thoracic US training, residual diagnostic inaccuracies persisted in differentiating pulmonary conditions.^[27] Examples of diagnostic disagreement between prehospital and ED US include conditions such as pulmonary edema, pneumothorax, and pericardial effusion, where image quality or misinterpretation led to inconsistent findings.^[27,36,39] These discrepancies, particularly when related to image acquisition or interpretive error, suggest that focused and condition-specific training may help reduce misdiagnosis.

While the results highlight opportunities for correctly triaging patients, incorrect triage remains a potential threat in the presence of early diagnostic error, with cascading effects on transport decisions and resource allocation.^[25,34] Several studies highlighted how incorrect triage may result from initial diagnostic errors during prehospital US.^[36,37,39] For instance, Khalil et al reported that inadequate training limited the detection of tension pneumothorax, potentially delaying life-saving interventions.^[36] Similarly, El Zahran et al emphasized that US-driven triage may be altered by early misinterpretation, risking unnecessary procedures or suboptimal hospital destination decisions.^[37] These examples suggest that structured and scenario-specific training could mitigate such risks, even when image quality is suboptimal. Closely linked to misdiagnosis are the risks of incomplete or inappropriate interventions, which can delay definitive care or lead to unnecessary procedures.^[33,36,40] Khalil et al reported that short-term training did not significantly improve tension pneumothorax detection, raising concerns about potential mismanagement in high-stakes scenarios.^[36] Collectively, these studies highlight how limited training, variable diagnostic performance, and system-level inconsistency can contribute to significant clinical risk. These findings collectively underscore the importance of robust training, supervision, and system-level safeguards to mitigate the risks associated with expanding US use in prehospital environments.

This study provides one of the 1st structured evaluations focused specifically on paramedics in the prehospital US literature. Methodologically, we searched 4 major databases (PubMed, Scopus, Web of Science, and MEDLINE) using explicit search terms within a prespecified time window. An a priori analytic framework integrated content analysis, semiotic coding, and SWOT categorization, enabling qualitative themes to be operationalized as indicators and summarized with simple frequency counts. The evidence base spans multiple regions and includes both conceptual and clinical designs, supporting external relevance. Treating indicators – rather than whole studies – as the unit of synthesis helps minimize heterogeneity-related bias while preserving clinically meaningful signals. The work was conducted by a multidisciplinary team with expertise in EMS/prehospital US and qualitative synthesis, enhancing the credibility of the interpretations.

This study has several limitations. Heterogeneity in study design, training contexts, and outcome reporting limits comparability and may attenuate or inflate indicator frequencies. To reduce this risk, synthesis was conducted at the level of indicators rather than entire studies, and results were reported as absolute counts and percentages. Future research should adopt harmonized outcome sets and prospective multicenter designs. The use of SWOT and semiotic content analysis introduces potential classification bias arising from researcher interpretation, which could shift category frequencies in either direction. A predefined coding framework with consensus review and an audit trail was applied to enhance consistency; independent dual coding with inter-rater reliability is recommended for subsequent studies. Restriction to selected bibliographic databases and published sources raises the possibility of publication bias and under-representation of gray or non-indexed literature, potentially under or overestimating some signals. Broadening future searches to include gray-literature sources and registries would mitigate this concern. Language bias is possible because non-English publications were not comprehensively included; however, the predominance of English in indexed scientific publishing (>90%) partially mitigates this risk.^[41] Incorporating non-English or translated sources in future syntheses would further reduce it. Variation in EMS organization and resources across countries constrains generalizability. Stratified analyses by system characteristics and adoption of context-adapted protocols are advisable. For some variables, single-statement coding was necessary and may misestimate prevalence. Aggregation across multiple studies limits this effect, and future work should use multi-item measures and triangulate with quantitative performance metrics.

5. Conclusion

This study provides one of the 1st structured evaluations focused specifically on paramedic-performed prehospital US, synthesizing feasibility, diagnostic performance, and system integration within a semiquantitative SWOT framework. Across the literature, the dominant strength was early diagnosis and its contribution to time-sensitive decision-making, with multiple reports showing that trained paramedics can acquire and interpret clinically useful images that inform triage and destination planning in respiratory distress, trauma, and cardiac arrest. At the same time, 2 consistent weaknesses emerged: insufficient longitudinal training and supervised field exposure, and the absence of standardized implementation protocols governing indications, target views, documentation and handover, quality assurance/archiving, and operational accountability. Opportunities centered on scalable training solutions – particularly blended/digital education and simulation – together with tele-US for real-time supervision and feedback, and maturing device/QA ecosystems that enable routine auditing and learning loops. The principal threat was misdiagnosis under real-world operational constraints, which can cascade to incorrect triage and, in some circumstances, inappropriate or delayed interventions.

Taken together, these findings support a pragmatic pathway for safe scale-up: implement structured, longitudinal, and condition-specific training with supervised practice; adopt service-wide, context-adapted protocols and clearly defined roles; embed quality-assurance processes with explicit maintenance responsibility; and standardize equipment while leveraging tele-enabled guidance where feasible. Priorities for future research include multicenter prospective evaluations that link prehospital US processes to patient-oriented outcomes and assess the durability of skills under routine field conditions.

Author contributions

Conceptualization: Burcu Azapoğlu Kaymak, Merve Eksioglu.

Data curation: Burcu Azapoğlu Kaymak, Kadir Yilmaz.

Formal analysis: Merve Eksioglu, Kadir Yilmaz.

Investigation: Burcu Azapoğlu Kaymak.

Methodology: Burcu Azapoğlu Kaymak, Merve Eksioglu, Kadir Yilmaz.

Supervision: Burcu Azapoğlu Kaymak.

Visualization: Burcu Azapoğlu Kaymak.

Writing – original draft: Burcu Azapoğlu Kaymak.

Writing – review & editing: Burcu Azapoğlu Kaymak, Merve Eksioglu.

Supplementary Material

medi-104-e44868-s001.docx ^{(17.3KB, docx)}