Dials and Gel

The A4C Post or: How I Learned to Stop Worrying and Love the Apical Four Chamber View

Well, here we are, the apical four-chamber post. I know you are wondering, why would I start a post like that? It’s because I have been procrastinating on this post. After all, this is not my favorite exam. I would much rather be talking to you today about the PSLA or the excellent sternal notch view of the aortic arch I posted a few weeks ago. Nevertheless, here we are, so let’s get into this thing, shall we?

If you have been paying attention to our Facebook page in the last week (which you totally should), you may have noticed a few posts by Chris Meeks (yes, the one and the same of Mind Body Medic) centering around this view…

I couldn't see the distal aspect of the heart the other day…guess I have a problem with DEPTH perception..😬👊#emspocus #dadjoke

Posted by EMS POCUS on Monday, February 10, 2020

This view is called the apical four-chamber or the A4C. And as for me, as you can tell by how I opened this post, it is not my favorite exam. We will talk someday about what it is useful for, but know, it is an extremely useful view and provides a wealth of knowledge for prehospital clinicians. Still, its utility is not why I had a particular disdain for it. No, my reason for not liking it is a lot unoriginal and personal. I was absolutely shit at performing it. To be honest, it was embarrassingly for a long time, this view eluded me, seemingly tortured me like I was in the 9th circle of Ultrasound Hell. 

Let’s not go over my journey on how I finally overcame this seemingly tricky exam. Lessons learned, or how you can skip a lot of the stress I went through to get better at this exam. I feel this will be more important as it will save you some stress on your journey to learn ultrasound. 

The View

Remember, this view is looking up from the apex of the heart is toward the patient’s head. In other words, the very bottom of the heart, where the ventricles taper and meet, up toward the atria. Kind of like this:

Remember!! Don’t reverse the image or it won’t go well!

What you are looking for ultimately is this view of the heart:

Troubleshooting Fine-Tuning Advice

Probe Positioning– This is the key. You need to start this exam on every patient in the same spot, paying attention to the orientation of the probe marker (the little nubbin on the side of the probe that tells you which side of the screen things will be on) toward the patient’s left. The probe goes about where V4 would be placed for an ECG, this is a great spot to start out. 

REMEMBER! The numbing needs to point to the patient’s left. You also should be in cardiac mode.

Patient Positioning– As the students in our classes hear from all the time, be lazy. What? No, not like that, set yourself up for success. If you are having trouble getting the view you want by moving the probe, move the patient. This is called the “Mayo Technique,” have the patient put their arm over their head (or you move it if the patient can’t), and have the patient roll over onto their right side. This is where being in an ambulance has its benefits. Depending on which side of the truck you sit on (or can sit on), you can pull the patient toward you, so they are on their right side or stick your knee under their left shoulder and roll them slightly. This will let gravity do its job and allow the heart to rest against the side of the patient’s chest wall in a way that may make this exam easier to perform. 

Flying Inverted– For all of my fellow video game nerds, remember, when performing this exam, the probe orientation is inverted, meaning you are flying inverted on this exam. If you have no clue what I just said, remember, this exam is performed in “Cardiac” mode, everything onscreen is backward. I know, I can hear my voice from several years ago along with a chorus of ya’ll now, “why don’t we just learn it out of cardiac mode” or “why don’t we just turn the probe marker around,” or “why would cardiologist like images inverted.” To answer that, no, no, and not a clue. What I want you to take away from this is, please, please, for the love of everything, remember that these images are flipped. It can be especially dangerous, depending on the questions you are asking in your assessment to mix up the right and left of this exam. 

You Kinda Got It– You kind of got the view but not really. It doesn’t look quite right. Perfect, let me describe for you, using words only to describe a visual issue…nah, let’s not. Luckily I have this hand picture to help with this!

The Basics

Always remember your basics; more gel, press harder, movement, and stop. The only sin in ultrasound is not enough gel, make sure you have enough for the exam. Add more pressure to help visualize through tissue, sometimes this means leaving a red mark. Use large circular movements and then fine-tune them with smaller movements once you are in the right area (look for the big moving thing in this case :-). Stop, after 120 seconds, pull yourself out of the ultrasound quicksand, perform other exams, and come back to this one. You do not want to get stuck playing the ultrasound video game when there is patient care to be done or further assessments to do.

The concept that has helped me the most with this exam is persistence in practice. I cannot begin to express to you how important this concept is in ultrasound. There could be an entire blog post written about the circles of ultrasound hell avoided by this concept, but for now, just know that your persistence in practice will help you with the A4C. I know, easier said than done. Just like this post, I avoided the A4C like everyone avoids saying the “q” word at work. No one enjoys feeling the way you do when you aren’t successful with a skill. I never felt great struggling with this exam, but to be successful clinicians we must do what is uncomfortable. Feeling uncomfortable and learning to be comfortable with our feelings of uncertainty with new skills or skills that scare us, that’s what will allow us to reach those higher levels of clinical judgment our patients deserve. 

Don’t let me convince you that this is a tough exam, it was tough for me. For some, this exam is straightforward; others have found it challenging. What I am trying to get at is that it’s ok to struggle with this stuff. Everyone has struggled with one, two, or more exams. 

Deep breath, you’ve got this.   

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Further Learning


Bowman, J., Boitnott, J., & Miesemer, B. (2017). The point of care ultrasound handbook. EMSPOCUS LLC.

Ma, O. J., Mateer, J. R., Reardon, R. F., & Joing, S. A. (2013). Ma and Mateer’s emergency ultrasound(3rd ed.). McGraw Hill Professional.

Authors Note: All images are from “The Point of Care Ultrasound Handbook” published by EMSPOUCS LLC and written by J. Bowman, J. Boitnott, and B. Miesemer. Permission to use these images were expressly given by the publisher and authors. If you like these images and would like permission to use them, please contact them at info@emspocus.com.

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