By Elizabeth Simpson, The Virginian-Pilot
McClatchy-Tribune Information Services
Sept. 10–Say “ultrasound,” and most people think of cloudlike images of a baby’s heart, limbs or face inside the mother’s womb.
But the ultrasound is evolving into broader uses, earning it the moniker of “stethoscope of the 21st century.”
The pictures captured are not always as cute as babies: kidney stones, fluid in the belly, blood clots. But with growing concerns about the dangers of lifetime use of radiation, this imaging device is gaining favor because it doesn’t use ionizing radiation, is noninvasive and is usually less expensive than other methods.
A local team of doctors is involved in a movement to consider ultrasound first before tests such as X-rays and CT scans. The results of two studies launched in recent weeks could be instrumental in moving that idea forward.
One involves Eastern Virginia Medical School students, who for the first time began a curriculum that incorporates ultrasound instruction throughout their education, starting with first-year core classes such as anatomy.
The other study outfits Norfolk ambulances with 12 portable ultrasound units to help paramedics and EMTs diagnose patients in the field and during ambulance transport.
The devices can be used to see if a lung has collapsed, for instance. Or if there’s fluid around the heart. They also are helpful in guiding insertion of central lines, which are flexible tubes for medicine, transfusions and other fluids.
“Emergency physicians like myself have realized it’s an amazing decision-making tool that allows us to make quick decisions in an emergency,” said Dr. Barry Knapp, an associate professor of emergency medicine at EVMS who has been training EMTs to use portable ultrasounds on ambulances.
Over the years, the devices have become smaller, making them easier to carry and use for bedside care. They’ve also come down in price at a time when health care costs are a growing concern.
They’ve proven themselves useful as tools of triage — as so-called “point-of-care” treatment at the bedside and in remote areas or Third World countries, where technology is harder to come by.
Dr. Alfred Abuhamad, chairman of obstetrics and gynecology at EVMS, has worked on ultrasound innovations such as crafting software that can detect heart problems in fetuses.
Now he’s trying to make the imaging devices more familiar to physicians by helping develop a curriculum that incorporates use of 30 hand-held ultrasound units at the school. The idea is that if doctors are comfortable using the imaging devices as they would a stethoscope, they may be less likely to order a more expensive X-ray or CT scan.
“If you promote the idea with medical students early in their career, they will continue to use it as they go into the clinical setting,” said Abuhamad, president of American Institute of Ultrasound in Medicine. “We believe it’s so valuable, it needs to be started early.”
In the anatomy lab at EVMS, students bend over rows of cadavers on gurneys, a long-standing cornerstone of medical education. They slice through layers of fat and probe internal organs.
In another corner, students are poised over tubs of a gelatinous material that contain such objects as a balloon with a marble inside, a plastic cow and a shark.
The students use wands attached to the hand-held ultrasound units — which are a little larger than a cell phone — to probe the gel and capture an image of the objects.
“Think of the image as a wedge of cake,” said Dr. Craig Goodmurphy, assistant professor of pathology and anatomy at EVMS. “Hold the wand like a pencil and anchor it. You don’t want it floating around.”
The key to a proper image is putting the probe in the right spot, embedding it into tissue, fanning it in the right direction and understanding the angles that will produce the best pictures.
Eventually, they’ll use the units on organs from cadavers and standardized patients, who are people the school employs to simulate medical conditions.
Based on the principal of sonar, ultrasound uses high-frequency sound waves to make pictures of the inside of the body. Because the images are captured in real time, they can show the structure and movement of the body’s internal organs, as well as blood flowing through vessels.
Ultrasound waves pass easily through fluids and soft tissues, so organs such as the uterus, gallbladder and liver are easy to scan. However, the waves can’t penetrate bone or gas, so the device is not useful for regions surrounded by the skull, for instance, and organs that contain gas or air. Large people are harder to scan because of the layers of fat.
Handheld units cost $7,000 to $10,000 but are not as precise as larger, more expensive equipment.
The EVMS units were provided by a grant from General Electric, which will track their use by the students through their education and later in clinical settings.
“We’re teaching them the use of bedside ultrasound,” Goodmurphy said. “It’s skill-dependent, but we’re working with millennials here so they’re digital savvy.”
Ultrasound has been a tool in medical diagnosis since the 1940s. It has been particularly helpful in the field of obstetrics because it’s noninvasive and doesn’t use radiation, making it safer for the fetus. Cardiologists and internal medicine doctors also have employed the technology for years.
Use in the emergency field has grown during the past 15 years. Norfolk Fire-Rescue Station One in Norfolk just received its first ultrasound machine, one of 12 being distributed to the city’s fire stations as part of a study by another ultrasound company, SonoSite.
Knapp has trained 90 paramedics and EMTs on the devices, and in the next few weeks they’ll start using them in the field.
“It can answer a ton of questions in a short amount of time,” Knapp said as he gave a demonstration using paramedic Doug Bondy.
For instance, in heart attack victims, ultrasound can determine whether the heart is beating and whether there is fluid around it. A check of the abdomen can spot fluid coming from the spleen or liver, a sign of a rupture.
“That period of time between when they pick them up and deliver them to the door can be put to use to get resources lined up at the hospital and get their team ready to start treatment to lessen the injury to the heart muscle,” said Harry Worley, battalion chief at Fire Station One.
Knapp said the SonoSite study will examine whether the early information will speed, and improve, delivery of care.
Dr. Barry Goldberg, director of diagnostic ultrasound at Thomas Jefferson University Hospital in Philadelphia, said he believes ultrasound imaging is underused and it could help reduce health-care costs.
But some ultrasound technicians and radiologists are concerned that doctors who are less adept at using the devices will fail to properly diagnosis conditions. Ultrasound technicians attend two- and four-year college programs or are trained at hospitals.
“There’s some concern that once you are in control of the patient and the referral you can increase your income,” Goldberg said. “People need to be adequately trained, and they need to know what they are seeing and when to refer it to someone else.”
He said he hasn’t seen any evidence of doctors failing to make proper referrals.
“They refer to us when it’s needed, because they don’t want to lose their patient.”
Another growing use for ultrasound is in remote regions that lack sophisticated technology. Abuhamad has worked with a number of coalitions to bring ultrasound skill to Third World countries to improve maternity care.
Ultrasound companies have donated equipment worth millions to clinics in places such as Haiti and Somaliland. Abuhamad and other health-care professionals train doctors and midwives in clinics to use the equipment.
Some of the units are battery powered, which is good in places where electricity is unreliable. They are small enough to be shipped back to the company for repairs.
Abuhamad has been to Haiti several times — he was training people in Cange during the 2010 earthquake and switched from teaching ultrasound technique to providing emergency care for victims evacuating from Port-au-Prince, the capital city. He plans another trip next year.
Women in some of the these areas are seen only by midwives in remote clinics. If a midwife can determine that a baby is upside down in the uterus or that the mother is carrying twins, she’s more likely to go to a hospital rather than have a home birth.
“There are midwives who have never seen a computer in their lives who by their fourth day are scanning independently,” Abuhamad said.
Whether ultrasound is in the hands of medical students, paramedics or midwives in remote areas, he said, it has the power to save lives and money: “Looking into the future, it’s an ideal modality to reduce the cost of care.”
Elizabeth Simpson, 757-446-2635, firstname.lastname@example.org
(c)2012 The Virginian-Pilot (Norfolk, Va.)
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