Ultra-Sound, Ultra-Quick Decisions

ULTRASOUND EQUIPMENT HAS BECOME MISSION-ESSENTIAL WHETHER STATESIDE OR DEPLOYED FOR HEALTH CARE PROVIDERS.
 

From the Mayo Clinic to the mountains of Afghanistan, rapid advances in ultrasound technology are enabling physicians to make better-informed and faster decisions. Not only have image quality and data capabilities improved, but the package is becoming much smaller, enabling ultrasound to be much more practical and portable than in the past.

That is abundantly evident among forward surgical teams, combat-support hospitals, shock trauma platoons and expeditionary medical facilities in Iraq and Afghanistan. Physicians are using portable sonography to diagnose patients, reducing the need for invasive diagnosis procedures, as well as reducing the need to send the patient to a higher-level facility for radiologic imaging. And a common use for the product is obtaining quick information in order to answer go, no-go questions pertaining to triage.

Prior to having ultrasound in the field, in order to determine whether there was internal bleeding in the abdomen, doctors often had to make an incision there (a peritoneal lavage). Ultrasound has replaced that type of procedure, going from invasive to non-invasive. Once it is determined what is going on internally, a quick decision can be made how to triage the patient.

During the Gulf War, the ability to place medical assets very close to the front lines was limited because of the large footprints associated with the equipment. In response, DoD launched an initiative to substantially reduce that footprint, resulting in a much greater ability to move medical resources closer to the battle. The military set out to change the way it provides medical triage to troops, and solicited new equipment from industry.

The Defense Advance Research Project Agency provided funding to Bothell, Wash.-based SonoSite, at the time a division of ATL, Ultrasound to develop a very small ultrasound system. In 1999 SonoSite released that product, a 5.4-pound, handcarryable unit called the SonoSite 180 system. Used by medical teams throughout Iraq and Afghanistan (as well as in both military and civilian stateside facilities), it helps identify abdominal or chest bleeding, vascular damage, the presence of foreign bodies and many other conditions.

Trauma and vascular indications are the most common reason for use of ultrasound at the busier trauma facilities in Iraq, said Colonel Donald Jenkins, trauma medical director for U.S. Central Command, Joint Theater Trauma System. It is used to identify internal bleeding after major trauma, to identify the best site for a large central IV catheter and to determine injury to major blood vessels. “Very few radiologists or ultrasound technicians are in theater, but the ultrasound technology is everywhere, every little outpost with a physician that I have visited is using ultrasound,” recounted Jenkins. “Clinicians are being trained to use ultrasound in the CONUS [continental United States] medical treatment facilities and then applying that knowledge here in theater.”

He said that many disease, non-battle injury conditions are also amenable to ultrasound diagnosis, such as deep venous thrombosis, often seen after an injury or prolonged immobility, like a long airplane ride from the United States to the theater. Similarly, gallbladder disease diagnoses, certain cardiac tests, gynecologic examinations and other diagnoses are made possible with ultrasound.

Colonel Thomas A. Rozanski, Colonel Jeffery M. Edmonson and Colonel Sheila B. Jones, who were connected with the 21st Combat Support Hospital North, Forward Operating Base Diamondback, Mosul, Iraq, wrote in a paper that “…found ultrasonography to be most valuable in trauma (FAST) examinations, and abdominal imaging. However, we used the device for multiple other examinations, including some unusual indications such as imaging of the ocular globe, fluid collections in the popliteal fossa, shoulder varicosities, and complex subcutaneous masses.”

Ron Dickson, vice president for government and military sales at SonoSite, added that examining the eye for retinal damage another common use, is determining whether heart is beating, or whether the cardiac sac is punctured. And doctors in the field it for everyday things well, such as sick call.

Jenkins pointed out, “The fact that the technology has been made easy to use, foolproof—or as I often say as a trauma surgeon, surgeonproof— and will re-set to baseline by simply re-booting makes this very usable. All the services use the same type of device, so parts are interchangeable and the spectrum of probes for various organ system evaluations from a single machine really makes this tool valuable.”

Jenkins continued, “It’s rugged. In fact, the machine that was brought to Balad [Iraq] by my Army colleagues early in 2004 is still there in everyday use in the ER. Meanwhile, every X-ray machine has been replaced at least once, the CT scanner is on version number four, even the tents are the third ones used at this site. But our portable ultrasound device keeps on chugging along.”

The 180 system is designed with the capabilities of a mid-range product. “When you have a hand-carried system, your use model is much different than you would find with a perinatologist at Cedar Sinai Medical Center who’s doing 4-D,” said Dickson. “The 180 system is designed for rapid use to give you quick answers.” SonoSite has other product platforms that are more geared toward broader hospital or clinic usage, including the new high performance MicroMaxx system.

TO THE POINT OF CARE

Improvements in ultrasound technology are improving workflow and productivity, explained Dickson. “With the traditional technology, if a physician needs to perform an ultrasound exam, the technologist must unplug the ultrasound system, unhook it from the hospital IT network, and make sure they’ve got all their probes and their gel. And then they set off pushing a 300 to 400 pound piece of equipment down the hallway, hoping for an elevator to open with nobody in it. Once they get to where they’re going they must maneuver between beds and try to find an electrical outlet, not rolling over any cables in the process. Once the exam is complete, they must make the same trek back to the imaging department. Not only is this a hassle, but it takes a huge amount of time affecting patient throughput.”

The smaller systems can readily go to the point of care—as portable as a cell phone. Dickson added that instead of keeping the systems in the traditional imaging departments, hospitals are buying hand-carried systems to place in individual departments. “The doctor doesn’t even have to call down any more to wait for the imaging department to come up and do the exam. So it really has improved the efficiency of health care.”

Jim R. Brown, senior director of clinical and technical marketing at Phillips Medical Systems, Ultrasound Division, pointed out that surgeons are now regularly using ultrasound, and it is becoming more common in emergency rooms as well. “You’re starting to see ultrasound now migrate down to the point of care.”

Modern ultrasound machines have better ergonomic designs as well. The Society of Diagnostic Medical Sonography reported that ultrasound operators are at risk for musculoskeletal disorders such as repetitive stress injuries; an estimated 83 percent of sonographers will suffer some degree of work-related injury during their careers—at least if they’re using the older, less user-friendly technology.

“Today’s machines most often have programmable key functions, customizable panel designs, sophisticated imaging software as well as ergonomic improvements that not only enhance the imaging capabilities of the ultrasound system but also make the systems easier to use,” said Louise Kruz, cardiology marketing manager for Siemens. “Aspects like this makes it physically easier on the operator as well as improves diagnostic imaging outcome and workflow, and are core design factors in the Siemens line of ultrasound products.”

“In the old days, the machines weren’t designed very well for rapid deployment,” added Dickson. “Ergonomics and an intuitive user interface has really become a focal point in developing new equipment.”

THE FOURTH DIMENSION

Obstetrics is probably the most commonly known use of ultrasound, but that’s just one of the many applications. “Gall bladders, kidneys, liver, spleen, vascular…a busy cardiology practice could do maybe 3,000-5,000 echocardiograms in a year,” said Kruz. “Most of the biopsies that are done for prostate cancer are all ultrasoundguided.” Ultrasound plays a major role following mammography in the work-up for breast lesions.

She pointed out, “For ultrasound the rule of thumb is, it can be used on anything that’s not bone and that’s not filled with air.” X-rays, of course, are used to examine bone. And CAT scans are useful for looking at gas-filled structures such as bowels or lungs.

Siemens carries ultrasound products in all price points and configurations. And it places particular emphasis on developing systems for diagnosing difficult-to-image patients, such as patients who are obese, have breathing issues, are active or unable to remain still (pediatrics), or who have Renal disease, which is associated with a lack of water in the body.

Brown said that “We can even use ultrasound to look in babies’ brains to look for any abnormalities, especially premature infants. We’re also using ultrasound to look at musculo-skeletal type of abnormalities or sports injuries.” He affirmed that in addition to diagnoses, ultrasound can be used as a good guidance technique, such as for biopsies.

The Mike O’Callaghan Federal Hospital at Nellis AFB has requested the purchase of a Phillips iU22 ultrasound system. They need state-of-the-art ultrasound imaging for early detection and treatment of conditions including cancer, vascular disease, kidney disease, obstetric and gynecologic problems, and diseases of the breasts.

“The iU22 boasts an XStream Architecture system. That system allows multiple data streams to process simultaneously, resulting in optimal clinical performance in all modes and with all transducers,” said Master Sergeant Erica L. Perez, diagnostic ultrasound phase II course supervisor at Nellis. “The outcome is improved tissue differentiation and Doppler sensitivity. The iU22 also has automatic optimization for color Doppler resulting in maximum performance.”

Four-dimensional (i.e., 3-D plus realtime imaging) ultrasound technology is becoming more common and provides potential opportunity to obtain additional diagnostic information from ultrasound. In trasthoracic cardiology, for most patients, the frame rate and the image resolution is not yet meeting the desired clinical applications, according to Kruz. But she expects at some point in the future that technological advancements will make that possible.

Nevertheless, Kruz said that 3-D is especially effective at looking at the heart, via a transesophageal probe. “When you add on the capability of 3-D, you’re talking about beautiful image quality. So in the operative patient, you may provide a clinical benefit that they can’t get with 2-D imaging.”

And 4-D is making inroads. “We’re seeing pretty dramatic uptick in sales in 4-D capability for cardiology—about 60 to 70 percent of the premium systems are going with those advanced capabilities,” said Brown. “In radiology, adoption of 4-D is a little slower because the applications and the capability haven’t been there. But there’s an uptick in those areas as well.”

Another ultrasound technology, akin to 4-D, is holographic ultrasound. Traditional ultrasound uses the reflective properties of sound, which accounts for only about 3 percent of the sound that actually goes into the body. “Instead of looking at what’s reflected back, our technology looks at the other 97 percent of the sound that actually goes through the soft tissue in the body, and we make holograms out of that,” said Lura Powell, president and CEO of Advanced Imaging Technologies, Richland, Wash. “We generate very clear, highly detailed images of the soft tissue structures in the body. It’s very different from the type of images that you will traditionally see with ultrasound.”

With AIT’s technology, an ultrasound source sends a wave of sound through the body or the body part. And there is a second ultrasound reference source which matches the first, enabling the creation of a hologram in real time. “We get an image of the full field (or the entire cross section), different planes within the object. This provides data over the entire volume of the object,” explained Todd Garlick, principal engineer at AIT.

The technology is especially useful with breast imaging and image-guided biopsy, but is also cleared by the FDA for real-time orthopedic, pediatric and vascular imaging. “We get to see the entire anatomy rather than the very small wedge typical of conventional ultrasound. With that 3-D data set, you can determine the exact location of the object, whereas in a mammogram it’s an image where you don’t have any depth,” added Garlick. “The technology is well suited for dense tissue. It allows us to effectively image dense breast tissue, overcoming a significant limitation of mammography.”

THE FIGHTING STRENGTH

Whether it is in a small-town clinic, a busy hospital, or in a surgical tent in Iraq, the benefits of new ultrasound technologies are proving remarkable. As Rozanski, Edmonson and Jones recommend, such technology should be considered for all combat support hospitals, forward surgical teams and brigade-level medical companies. It is one additional contribution to “preserving the fighting strength” of the U.S. military. ♦

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