Introduction

Point-of-care ultrasound (POCUS) involves performing US examinations directly at the point of patient care in both prehospital and hospital settings.1,2 POCUS involves using US diagnostics by medical personnel who are not radiology specialists. This approach aims to reduce the time needed to diagnose patients and streamline therapeutic processes. As portable POCUS capabilities grow and machines become lighter and smaller while preserving image quality, the potential for POCUS to expand and be adopted into a multitude of environments grows, improving patient care and clinical outcomes.

This paper reviewed the available research on using US in prehospital settings and explored the limitations of integrating POCUS into these environments.

Ultrasound equipment used in emergency medicine

Technological advances and the resulting miniaturization of US devices have made the use of POCUS possible in prehospital medicine. Several manufacturers offer high-quality, portable US devices that often provide imaging quality comparable to that of stationary equipment. In challenging situations of prehospital medicine, wireless US transducers, which are becoming more widely available, prove to be ideal. Mobile US machines currently offer standard imaging options, such as B- and M-modes, as well as advanced Doppler options. These imaging modalities allow for qualitative and quantitative assessments of specific structures.

Competences and training of emergency medical teams

Over 10 years ago, POCUS in prehospital settings was identified as 1 of the top 5 research topics in emergency medicine. Since then, numerous publications have addressed the implementation and use of US for the early detection and management of life-threatening conditions in prehospital settings. However, implementing prehospital US faces notable challenges. The adoption of POCUS by emergency medical services (EMS) personnel varies across countries due to different structures of prehospital systems, available technology, and the development of targeted training programs. Despite reported experiences, the organization of training required to enable the use of emergency US in patient care remains unclear. Some publications cite a specific number of examinations to be performed during training. In addition to acquiring the skills, their maintenance over time must also be considered.1-3

Despite various educational approaches, several reviews suggest that, regardless of base qualifications, experience, duration, or quality of training, emergency physicians and paramedics may be able to gain proficiency in POCUS reasonably promptly.2-5 In a study by Quick et al,6 a small group of paramedics who underwent comprehensive education and training, and had extensive patient exposure, demonstrated POCUS interpretation accuracy similar to that of trauma surgeons. An observational study by Engelen et al,4 which investigated the use of prehospital POCUS in Germany, indicated that EMS physicians with limited US expertise could perform POCUS correctly in a prehospital setting.

In Poland, US examinations performed by emergency medical teams are not regulated by law.7 This has led to different interpretations of EMS personnel’s rights and capabilities to perform prehospital POCUS, resulting in unequal access to this modality across the country. Portable US devices have been regularly used at all air ambulance bases in Poland for about 10 years. Although POCUS during helicopter transport is not mandatory, it is often used in cases involving injured patients (Figure 1). The use of portable US devices during missions is regulated by internal helicopter EMS (HEMS) instructions. HEMS medical personnel, including doctors and paramedics, receives training in basic POCUS, and annual refresher courses and advanced training courses are held to maintain these skills. The Regulation of the Minister of Health of June 23, 2023 was the first to include emergency US in the list of procedures that may be provided by a paramedic, after completing a certification course. On June 5, 2024, the Regulation of the Minister of Health of May 22, 2024 took effect. The new regulation introduced a qualification course for paramedics, enabling them to perform US examinations according to emergency protocols. Graduates of Master’s degree programs in medical rescue studies, which are set to launch in October 2025, will receive the same qualifications.

Figure 1. Examples of point-of-care ultrasound use on board of a helicopter during a helicopter emergency medical services mission

Current clinical applications of prehospital point-of-care ultrasound

According to the available literature, POCUS is successfully used in several areas in prehospital settings, primarily for cardiac arrest, dyspnea, chest pain, and trauma (Figure 2; Table 1).

Figure 2. Point-of-care ultrasound goals in various clinical scenarios in prehospital emergency care

Table 1. Clinical algorithm of using prehospital point-of-care ultrasound

Clinical situation

Ultrasound protocol

Main purpose

Differential diagnosis

Cardiac arrest

FEEL, FATE

Assessment of cardiac activity

PEA vs pseudo-PEA

FATE, E-FAST

Identification of reversible causes of cardiac arrest

  • Hypovolemia;
  • Cardiac tamponade;
  • Pneumothorax;
  • Pulmonary embolism

FATE, vascular ultrasound

Guidance of interventions during CPR

  • Endotracheal vs esophageal tube placement;
  • Effectiveness of chest compressions;
  • Post-ROSC assessment

Thoracoabdominal trauma

E-FAST, CRAFT

Detection of free fluid

  • Peritoneal free fluid, cardiac tamponade;
  • Pleural effusion;

Detection of pneumothorax

Pneumothorax

Multiorgan trauma

CRAFT

Assessment of head injuries

Elevated ICP

Chest pain, dyspnea

FATE, LUS

Differential diagnosis

  • Myocardial infarction;
  • Acute aortic dissection;
  • Aortic stenosis;
  • Hypertrophic cardiomyopathy;
  • Pulmonary embolism;
  • Cardiac tamponade;
  • Pneumothorax;
  • Pneumonia;
  • Pulmonary edema;
  • Pleural effusion

Abbreviations: CRAFT, Cranium, Respiratory, Abdomen, Cardiac Function, and Trauma Integration; CPR, cardiopulmonary resuscitation; E-FAST, Extended Focused Assessment with Sonography for Trauma; FAST, Focused Assessment with Sonography for Trauma; FATE, Focus-Assessed Transthoracic Echocardiography; FEEL, Focused Echocardiography in Emergency Life Support; ICP, intracranial pressure; LUS, lung ultrasound; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation

Cardiac arrest

The International Federation for Emergency Medicine Consensus Statement recommends using US during rhythm check in cardiac arrest without prolonging interruptions to chest compressions.8 Many emergency medicine societies require US training, including its use during cardiac arrest. POCUS is included in the current guidelines of the European Resuscitation Council (ERC)9 and the Adult Cardiopulmonary Life Support (ACLS).10 In cardiac arrest, prehospital US can be a valuable tool for EMS personnel to assess cardiac activity, identify reversible causes of cardiac arrest, and guide interventions.

The REASON (REscue with Advocacy, Emergency Sonography, and Outcomes in Non-traumatic cardiac arrest) trial was a large multicenter nonrandomized prospective observational study that investigated the use of POCUS in patients undergoing cardiac arrest, to assess for cardiac activity and its correlation with survival.11 First, the study showed that 54% of the patients with pulseless electrical activity (PEA) had cardiac activity on initial US. Although manual pulse checks are still a part of standard ACLS protocols, POCUS offers a potentially faster and more reliable method of pulse detection. It has been proven that cardiac US provides a more objective measure of pulse than manual palpation when used to assess ventricular systolic activity.

The presence of cardiac activity on US differentiates true PEA from pseudo-PEA. The guidelines emphasize that there is no standardized definition of cardiac motion visualized on POCUS during cardiac arrest. Isolated movement of a wall fragment or myocardial tremor, without a change in ventricular volume, as well as isolated movement of the heart valves, do not meet the criteria for a pseudo-PEA diagnosis. Pseudo-PEA is associated with a higher likelihood of return of spontaneous circulation (ROSC) and survival. The REASON study found that even the subtle presence of cardiac activity on US was significantly associated with survival to hospital admission and discharge. Conversely, the absence of cardiac activity was associated with a very low survival rate (0.6 %).11 A study by Heydari et al,12 which examined adult patients with nontraumatic cardiac arrest and nonshockable rhythms, demonstrated that the presence of cardiac motion on initial POCUS was associated with ROSC. Patients with detected cardiac activity on initial POCUS had markedly better outcomes, with ROSC rates of 52.1%, as compared with 12.3% for the patients without cardiac motion. Survival to hospital discharge among the patients lacking cardiac activity was only 0.69%.

For patients experiencing ventricular fibrillation or pulseless ventricular tachycardia, rescuers should prioritize rapid and safe defibrillation. However, identifying reversible causes is fundamental to improving resuscitation outcomes in nonshockable rhythms. Current ERC and ACLS guidelines recommend using POCUS to detect these causes in nonshockable rhythms (PEA and asystole).9,10 These reversible causes can be described as hypoxia, hypokalemia / hyperkalemia, hypothermia / hyperthermia, and hypovolemia / tamponade, tension pneumothorax, thrombosis, and toxins (commonly referred to as 4Hs and 4Ts). Four of them— hypovolemia, cardiac tamponade, tension pneumothorax, and acute pulmonary embolism—can be diagnosed using POCUS.13 However, limitations of interpreting US findings in patients with cardiac arrest should be considered. The guidelines especially caution against overinterpreting right ventricular dilation in isolation as an indicator of massive pulmonary embolism.11 Right ventricular dilation begins a few minutes after cardiac arrest onset, as blood shifts from the systemic circulation to the right heart along a pressure gradient. Furthermore, pre-existing pulmonary or cardiac disease can cause right ventricular dilation, pulmonary hypertension, and right ventricular dysfunction.

Other applications of POCUS during cardiopulmonary resuscitation (CPR) include confirming endotracheal intubation, which is faster than capnography,14 guiding the optimal hand positioning during chest compressions, using vascular US or transesophageal echocardiography, and postresuscitation assessment.15

The termination of resuscitation efforts remains a debated topic. Current guidelines consider factors, such as whether the event was witnessed, the initial rhythm, the duration of CPR, and the underlying cause.9,10 However, integrating POCUS offers a novel approach that may improve decision-making during CPR. A prospective study by Heydari et al12 found that cardiac standstill lasting at least 10 minutes was a highly specific predictor of nonsurvival, with 100% specificity, and the absence of ROSC. These findings are consistent with those of Kim et al,15 who reported a sensitivity of 90%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 93.3% for non-ROSC when cardiac standstill lasted 10 minutes or longer. These results reinforce the role of serial POCUS in identifying futile resuscitation and guiding termination decisions. Nevertheless, current resuscitation guidelines9,10 caution against using US solely for prognostication in cardiac arrest, particularly for terminating resuscitation efforts.

Integrating POCUS into cardiac arrest management poses challenges. Some researchers point out that performing US can distract the rescuer from patient care in some situations, which can lead to reduced situational awareness. In a small study conducted under simulated conditions, van der Geest et al16 assessed the impact of performing US on the distraction process. In this prospective simulation trial, 75% of the HEMS physicians failed to notice a deterioration in their patient’s condition because they were preoccupied with performing US. Several studies have raised concerns that US imaging during CPR may disrupt compressions and negatively impact resuscitation outcomes. In studies by Reed et al,17 Clattenburg et al,18 and Huis et al,19 paramedics’ use of POCUS during CPR was associated with a significantly increased pulse check duration, nearly doubling the maximum 10-second duration recommended in the current guidelines (17–21 s, depending on the study). Several strategies have been proposed to minimize these interruptions. US protocols used in cardiac arrest are based on a stepwise approach with 4 phases that are repeated cyclically to avoid prolonging unintentional pauses in chest compressions.15 The examination should always be performed by the most experienced sonographer on the resuscitation team, who is not directly involved in other activities. Finally, noncardiac US, such as abdominal or lung US, may be performed during chest compressions.9,10

Trauma

According to the World Health Organization, nearly 5 million people die from injuries each year worldwide, accounting for up to 9% of all global deaths.20 For people under the age of 40 years, injury is the leading cause of death. Following the “treat first what kills first” principle, active noncompressible bleeding in major body cavities and the retroperitoneum must be diagnosed and addressed immediately in trauma patients. Polytrauma management requires a well-developed, standardized system. The ABCDE approach20 is a systematic, prioritized method of assessing and treating critically ill or injured patients by addressing the following elements from which its name is derived: airway, breathing, circulation, disability, and exposure.

POCUS has long been an important tool for assessing trauma patients.21-25 With portable US technology, the entire body can be scanned and classified according to the trauma scoring system in just 5 minutes. This method provides a reliable and convenient basis for diagnosing and treating serious injuries, as well as for controlling and evacuating casualties.

The Extended Focused Assessment with Sonography for Trauma (E-FAST) protocol created in 2004 is a rapid bedside US examination that quickly assesses life-threatening injuries in trauma patients.24,25 The protocol involves evaluating the peritoneal cavity for bleeding, the pleural cavity for pneumothorax and pleural hematoma, and the pericardial sac for tamponade. This allows for a faster diagnosis and treatment. Most scientific society guidelines currently recommend the E-FAST as the standard of care for trauma. The E-FAST protocol, focuses on 4 simple questions: 1) Does my patient have free fluid in the peritoneal cavity? 2) Does my patient have free fluid in the pleural cavities? 3) Does my patient have signs of pericardial tamponade? 4) Does my patient have pneumothorax?

A prospective observational study by Press et al26 demonstrated a positive predictive value of 98% for required intervention due to pneumothorax, as well as a positive predictive value of 50% and a negative predictive value of 96% for laparotomy due to intra-abdominal fluid. Studies by Quick et al,6 Ketelaars et al,27 and Roline et al28 demonstrated a high level of agreement between US assessments performed by trained prehospital providers and changes in treatment for 20% of trauma patients. A systematic review of 34 studies with 8635 participants29 evaluated the diagnostic accuracy of POCUS for thoracoabdominal injuries in patients with blunt trauma. The study confirmed high specificity (96%) of POCUS in this population. According to the authors, it can help avoid wasting resources, overtreatment, and unnecessary invasive procedures because false-positive findings are very unlikely (3.1%). The accuracy of POCUS in identifying chest injuries, such as pneumothorax, was remarkable, with a sensitivity of 96% and a specificity of 99%. However, despite the advantage of this modality’s high specificity, a negative examination bears a relevant risk of being a false negative (negative predictive value of 90%). If the prior probability of thoracoabdominal trauma is high, a negative scan may be caused by centralized circulation and limited arterial perfusion of injured solid organs. Positive results are almost always trustworthy and should prompt bleeding control measures. Negative scans, however, must be confirmed on reference examinations, such as computed tomography (CT), or by sequential POCUS and clinical observation. This is particularly important in pediatric trauma, where POCUS sensitivity is only 62%.

POCUS can be incorporated into triage algorithms for natural disasters, such as earthquakes and floods, as well as for mass casualty situations, including combat zones.30 Identifying intra-abdominal or pericardial free fluid, tension pneumothorax, or cardiac activity using POCUS helps assign patients to different color categories for the mobilization and allocation of limited treatment resources. Portable US was used to triage patients after the 2010 Haitian earthquake.31 Investigators noted that US results influenced care in 70% of the cases. Following the 2008 Wenchuan earthquake,32 US was reported to have a 91.9% sensitivity and 96.6% specificity for diagnosing abdominal injuries.

It is important to note that the traditional E-FAST,23,24 which is used in many trauma protocols, does not evaluate intracranial structures that can be damaged by craniocerebral trauma, a leading cause of death in trauma patients. POCUS-CRAFT33 is a new proposal that integrates POCUS with clinical data, and it comprises 5 components: cranium, respiratory, abdomen, cardiac function, and trauma integration. This protocol expands upon E-FAST by adding elements for neurological and functional myocardial evaluation. Adding a head assessment component using transcranial color-coded duplex (TCCD) Doppler sonography to the expanded E-FAST protocol enables a comprehensive evaluation of trauma patients in areas with limited access to CT. It also allows for early identification of elevated intracranial pressure and selection of patients at a significant risk of sudden neurological deterioration (Figure 3).

Figure 3. Point-of-care ultrasound, Cranium, Respiratory, Abdomen, Cardiac Function, and Trauma protocol flow chart31

Differential diagnosis of chest pain and dyspnea

Shortness of breath and chest pain are the most common reasons for immediate admission to the emergency room among adult patients.34 Initial management can be challenging due to a broad range of potential diagnoses, many of which are life-threatening and require rapid identification and management. This wide spectrum often requires laboratory and radiologic testing in addition to clinical evaluation, which can cause unnecessary delays. POCUS has shown promising results in accurately diagnosing patients with dyspnea and chest pain.34-37 Several elements are important in the US assessment of patients with these 2 symptoms, including echocardiography, inferior vena cava assessment, and lung US (LUS).

Numerous studies have shown that POCUS has excellent diagnostic accuracy for pathologies commonly encountered in patients presenting with chest pain and shortness of breath.38-40 Often, this accuracy is higher than that of traditional diagnostic modalities. For example, Ünlüer et al41 reported a sensitivity and specificity of 93% for diagnosing pleural effusion with bedside US, using CT as the gold standard. Martindale et al42 found a 74% agreement between lung US and CT findings (as compared with the 58% agreement with chest X-ray) in diagnosing pulmonary edema. In critical care cases, bedside lung US has been reported to yield a diagnosis for patients with acute respiratory failure in 90.5% of the cases.43

POCUS is a valuable tool for diagnosing and managing heart failure (HF), especially for detecting pulmonary congestion.43,44 Prehospital LUS considerably improves the diagnosis and treatment of acute HF by enhancing the sensitivity and accuracy of paramedics’ diagnoses, which leads to earlier and more appropriate treatment.45 By enabling faster diagnoses, LUS reduces the time between a patient’s arrival and the start of treatment. Using the Lung and Cardiac Ultrasound protocol,46 which involves assessing 4 lung zones on each side of the chest, the left ventricular ejection fraction (LVEF) and the inferior vena cava diameter, has been shown to have an 83% sensitivity and 83% specificity in diagnosing acute HF as the cause of dyspnea (Figure 4).47

Figure 4. Differential diagnosis of dyspnea using point-of-care ultrasound; A – pulmonary edema; B – heart failure; C – pulmonary embolism; D – cardiac tamponade; E – pneumothorax; F – pneumonia; G – pleural effusion

According to Sobczyk et al,48,49 focused echocardiography allows both confirmation of acute myocardial ischemia and detection of the other life-threatening cardiac conditions, resulting in proper bedside decision of directed treatment. Other than significant cardiac pathologies were found in 46.52% of the patients with excluded diagnosis of acute coronary syndrome. Limited echocardiography is also a reliable method for diagnosing proximal aortic dissection.50,51 It provides a reliable value of the maximum diameter of the ascending aorta in comparison to both CT and direct intraoperative measurement.51 Moreover, echocardiography provides additional information that influences the operative technique of choice and identifies high-risk patients (cardiac tamponade, severe aortic dilatation, severe aortic regurgitation; Figure 5).51,52

Figure 5. Differential diagnosis of chest pain using point-of-care ultrasound; A – myocardial infarction; B – acute aortic dissection; C – severe aortic stenosis; D – hypertrophic cardiomyopathy; E – pulmonary embolism; F – cardiac tamponade; G – pneumothorax

In 2010, Ahn et al53 created a focused, integrated bedside US protocol for systematically evaluating patients presenting with acute respiratory distress, chest pain, or symptomatic hypotension in the emergency department. They named it Sonographic Evaluation of the Etiology of Respiratory Difficulty, Chest Pain, and Hypotension Using 8Es (SEARCH 8Es). The 8 Es refer to: empty thorax, edematous lung, E-FAST, effusion, equality of the right and left ventricles, EF, aorta exit, inferior vena cava entrance, and endocardial movement. The SEARCH 8Es protocol helps emergency providers narrow differential diagnoses, increase diagnostic confidence, and accurately assess patients with dyspnea, chest pain, or symptomatic hypotension. The SEARCH protocol is very similar to the well-known Rapid Ultrasound for Shock and Hypotension (RUSH) protocol,54 which is used in intensive care and additionally includes an assessment of deep vein thrombosis in the lower limbs. The RUSH protocol is a structured approach using POCUS to quickly evaluate the cause of shock in unstable patients. It involves assessing the “pump” (heart), “tanks” (intravascular volume), and “pipes” (large vessels) to differentiate between hypovolemic, cardiogenic, obstructive, and distributive shock.

POCUS is a powerful tool for evaluating patients with dyspnea and chest pain. It enables clinicians to rapidly and noninvasively assess various clinical conditions at the bedside, helping them make timely and accurate diagnoses and guide appropriate treatment.

Limitations

POCUS plays a very important role in emergency medicine, but its use in prehospital settings is limited. For many years, there were no legal or systemic conditions that permitted the use of US in these circumstances, which resulted in unequal access to this diagnostic tool across the country. Despite the creation of qualification courses on POCUS protocol use, there is still a lack of uniform educational solutions that specify the minimum number of examinations required to become proficient in this form of patient diagnosis. Maintaining acquired skills requires constant practice, preferably under the supervision of a qualified sonographer, which is difficult to achieve outside of hospital settings.

The quality and accuracy of tests performed in prehospital settings may be considerably limited by the technical capabilities of available mobile devices. Additionally, conducting examinations at the scene of an incident or in a moving ambulance can be challenging due to limited space and adverse weather conditions. The limited number of paramedics on emergency response teams forces crews to prioritize tasks during an incident. It should be emphasized that, while US is highly specific for diagnosing numerous emergency conditions, its sensitivity is often limited. A negative test result does not always mean that a given pathology can be ruled out. Conversely, there is also a risk of false-positive diagnoses, which may lead to incorrect treatment and transport decisions.

Administrators responsible for the proper functioning of emergency medical teams believe that the introduction of US as standard ambulance equipment would involve high implementation costs. These costs include the purchase of mobile US machines, staff training, and equipment maintenance.

Practical tips for the use of point-of-care ultrasound by emergency medical teams

Based on the available literature and the authors’ experience, the E-FAST protocol is the most commonly used in emergency medicine. From a practical point of view, however, the POCUS-CRAFT protocol seems to be the most useful in prehospital settings. It can be used for trauma patients and individuals experiencing chest pain or shortness of breath. Furthermore, in specific clinical situations, individual elements of the protocol can be used without performing a full examination. The biggest barrier to using the CRAFT protocol is the necessity of mastering the TCCD examination and having a device with the pulsed-wave Doppler option.

There are many training programs, workshops, and US courses designed to help paramedics and clinicians develop basic US skills. However, it is important to note that completing a course alone is not enough to become highly competent in POCUS. Scanning techniques and image interpretation are skill-based competencies that require hands-on experience. For POCUS performed in prehospital settings, a lack of mentors trained in this field may be the most significant barrier to gaining extensive experience. This problem can be solved by using teletransmission of US images to hospital departments for online consultation.

Future directions

Thanks to continuous technological development, growing clinical awareness, and changes in legal solutions, the future of POCUS looks very promising. Modern US machines are becoming smaller, lighter, and more resistant to adverse weather conditions while maintaining excellent image quality.

In the near future, we can undoubtedly expect the development of telemedicine related to the teletransmission of US images directly to hospitals or specialists for assistance in interpreting the obtained views. This solution would be extremely beneficial, especially in areas located far from hospitals or in mass accident situations, where a rapid diagnosis can help determine the appropriate treatment center.

We can also expect artificial intelligence (AI) to play a larger role in supporting image interpretation and reducing the number of diagnostic errors. The use of AI in POCUS is unique for 3 main reasons: 1) image acquisition process; 2) availability of training data; and 3) presence of medical context.55 Rather than providing a final diagnosis, AI tools aim to assist with the quantification, measurement, and scoring of anatomical landmarks. For example, AI has been used to automatically calculate LVEF and detect A-lines and B-lines on LUS. It can also detect free peritoneal fluid and estimate bladder volume.56 Importantly, AI provides guidance during the image acquisition process.55,56 Currently, some devices have real-time feedback functions that evaluate the quality of the views. This technology is expected to advance, which could enable less experienced individuals to perform technically good examinations. However, it should be emphasized that despite the promising results, there is an equally growing concern over the applicability and trustworthiness of AI-powered algorithms in real clinical settings.

Conclusions

POCUS is a simple and rapid diagnostic method used in prehospital settings to extend the classic physical examination and support therapeutic decisions. Thanks to the miniaturization and increased availability of high-quality imaging equipment, POCUS is gaining importance.

The clinical applications of POCUS include: 1) echocardiography to differentiate the causes of chest pain or shock etiology; 2) LUS and echocardiography to differentiate the causes of shortness of breath; 3) integrated abdominal, chest, and transcranial US in patients with multiorgan trauma (E-FAST, CRAFT); 4) US in cardiac arrest to optimize the quality of advanced life support and search for reversible causes of cardiac arrest; and 5) vascular US to diagnose cardiovascular pathologies, such as deep vein thrombosis, stroke, and acute aortic conditions.

To improve the quality of examinations, it is important to be aware of the limitations of US use, such as operator-dependency, difficulty penetrating gas and bone, difficulty with high–body mass index patients, and potential misinterpretation or overconfidence.57 Even expert US sonographers have difficulties interpreting real-time imaging, performing examinations in a moving ambulance, and carrying out tests in pediatric patients.

Therefore, there should be an emphasis on increasing POCUS experience and developing educational systems in this area. Providing formal training to medical students, residents, and paramedics would maximize the benefits of POCUS use in emergency medicine. A desirable solution would be to base pilot implementation projects in cooperation between universities, scientific societies, and the Ministry of Health.