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Thursday, July 17, 2014

They do make an ultrasound probe that plugs into a USB port!

“They should make an ultrasound probe that plugs into your laptop. It could just hook into a USB port.”

Ultrasound technology has become progressively more accessible to doctors who aren’t radiologists. During my training, some obstetricians imaged the bellies of their pregnant patients to quickly see how the baby was lying in the womb and assess its progress. Other than that, ultrasound resided in the realm of the radiologists, who lived in dark rooms and interpreted blurry pictures for the rest of us.

Since ultrasound is not expensive and has many potential applications, far beyond just seeing fetuses, other specialties have adopted it and doctors in resource poor countries where there are no radiologists have come to rely on it for all sorts of information. Trauma surgeons and emergency physicians can use it to rule in or out life threatening conditions, and internal medicine physicians like me can improve on the accuracy of our physical exams and sometimes avoid the cost of more complex and dangerous imaging procedures. Ultrasound can be used to guide procedures, making them safer. The machines have become smaller and are even pocket sized. It’s all so very exciting.

So why not an app for the iPhone? Why not Google glasses with which one can see ultrasound images of the patient in front of me? Why not a wireless ultrasound transducer?

The possible avenues of progress in very portable ultrasound technology have been slow for various reasons. First, many people are happy with radiologists imaging the body and cardiologists imaging the heart using large and expensive machines. The system works. It doesn’t require the rest of us to learn ultrasound and the pictures are good and the rather large charges benefit hospitals. Bedside, ultrasonographers are looking for inexpensive machines and it is unclear how much the use of these will increase the revenue stream which drives much of what happens in research and development in medicine.

Having wandered through the health care device industry’s displays at many ultrasound conferences and having surfed the Internet I thought I knew what kind of technology was available for doing bedside ultrasound imaging. I had seen an ultrasound transducer that plugged into an iPhone made by a company called Mobisante, and had seen their iPad/transducer combo. The software was buggy and the pictures were not impressive and the whole package did not end up being handy or attractive. I bought the GE Vscan machine which is about the size of my hand, and like my hand, fits in my pocket. The pictures are good and it does most of what I want it to do. So when people asked about just buying a transducer for a laptop and plugging it in I told them that clearly that was a great idea but it didn’t exist.

Except that I was wrong. The company Interson, out of the Bay Area in California, makes transducers for imaging blood vessels, deeper structures such as abdominal organs, and cavities such as the throat and vagina/uterus. I had the opportunity to try their abdominal probe in the last few weeks. It is definitely a clever and versatile device, despite several drawbacks.

The probe is called SeeMore, which will probably not help sell the product. It is about as heavy as a small hardback book and it is a little big to have comfortably in a pocket. It has an inescapable resemblance to a personal vibrator which will also not help sell it. It is actually the same transducer that Mobisante used in their iPhone device. On the very positive side, though, it gives really good pictures of the abdomen, uterus and bladder. Its resolution is good enough that it could be used to rule in or out a pneumothorax, which my Vscan is not quite up to. Its image acquisition is slow so when looking at the heart it is not possible to see the delicate movement of the heart walls or valves, though it is possible to see grossly abnormal cardiac function or pericardial effusion from an abdominal approach. It does not do color Doppler, so it cannot give any indication of blood flow. It has its own software that loads quickly onto a laptop and it could be used with a tablet so long as it has a windows operating system.

The USB attachment can go into a USB to mini-USB converter so the tablet doesn’t even need to have a full size USB port. Once the software is loaded it has calculations that are user friendly and intuitive calipers for measurements plus all of the usual gain adjustments that a person might want. There is a button on the transducer that freezes and unfreezes the image. After images are stored they can be printed or transmitted easily as JPEGs.

If I worked in a bush hospital somewhere and needed my ultrasound just to evaluate unborn babies or critically ill or traumatized patients, this transducer would be just the ticket. If I used a laptop as I went from room to room, as I did at my last job, I can imagine information from this device being integrated seamlessly into my documentation as I examined the patient. The transducer I tried does not visualize superficial structures, like blood vessels or bones or tendons, abscesses or thyroids, but Interson makes a linear transducer that does. Each transducer costs $4000 new, and the software, support and hefty plastic case with tiny tube of ultrasound gel are included. My Vscan cost over $8000 and the cheapest portable ultrasound machine that hospitals in the US buy costs over $40,000 new. (Veterinary ultrasound machines and ones that are used in developing countries can cost much less than this, even in the sub $1,000 range for a used machine.) From where I stand this USB transducer is an affordable alternative for point of care ultrasound, though I do like a machine that gives better pictures of the heart.

What about the Google glasses thing? I think somebody has a patent for that, though it’s not commercially available. What about the wireless transducer? Yes. It exists. It is not Bluetooth, a proprietary short distance wireless connection that uses ultra-high frequency radio waves. It uses a different proprietary ultra wide band wireless connection which can handle more information. The one that I found is called the Freestyle, by Acuson, which is now owned by Siemens. It looks like a TV remote and I think it’s just for superficial structures.

As there is demand, these machines will get lighter, cheaper, more versatile and attractive. The potential is awesome and I’m looking forward to trying out new toys that will allow me more capably to help my patients.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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2 Comments:

Anonymous Anonymous said...

How are you planning on using ultrasound with little-to-no training? You do realise that sonographers and radiologists train for years in the art of ultrasound, and have an in depth understanding of the physics behind it to allow them to get the best quality images. I doubt you even know the difference between B-mode and M-mode, let alone power wave doppler and harmonics. In my experience people using these portable ultrasound machines inevitably a) find something that isn't there or b) miss something that is there, and in my years of experience at a busy imaging department we have had to do countless repeat ultrasounds to confirm/deny apparent findings done by untrained people on these inadequate machines. I've seen GPs refer people in for AAA seen on their ultrasound - turned out to be the bloody gallbladder!

Fine - go ahead, but don't tell your patient what you are doing is a replacement for a proper ultrasound with a decent machine under skilled hands. It's not.

July 17, 2014 at 3:28 PM  
Anonymous Anonymous said...

Bedside ultrasound is a different procedure than an ultrasound performed by a radiology technician and read by a radiologist. It is really an extension of the physical exam, and as such, often requires another imaging study to clarify what we think we see. As a clinician and bedside ultrasonographer I have a detailed history and physical to temper my interpretation of what I see. I also have less experience than technicians and a machine that gives pictures with less resolution than the larger and more expensive machines radiologists use. I try to limit my interpretation to those things which I am very confident about, and ask for more imaging when I am unsure. I have completed the certification as a sonographer, so I do know what M-mode and power doppler are, but that is neither necessary nor sufficient for competency in bedside ultrasound. As a group, we internists need to develop some guidelines about how to train ourselves adequately and how to define competence and scope of practice. This little device is just one of many that is on the market to make it convenient to bring ultrasound into the clinic and to the bedside. The implications are a big issue and one that I have addressed elsewhere, and will need ongoing work. In the meantime, bedside ultrasound, here in the US and overseas, is making a huge and positive impact on improving diagnosis and treatment.

July 18, 2014 at 3:50 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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