Sound Decision-Making: Ultrasound Finds Its Place in Every Forum

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Robert Tillotson, MD, utilizing Zonare’s convertible ultrasound platform in the St. Michael’s Hospital emergency department in Stevens Point, Wis.

As ultrasound devices have continued to shrink in physical size while improving in diagnostic quality, they have gained adoption in emergency departments (ED) and in other critical-care areas to rapidly assess a variety of diseases. However, some radiologists remain concerned about the efficacy of the growing use of ultrasound in the ED, as well as other settings, and portend that the newer, more advanced ultrasound techniques, along with more seasoned reading skills, are required to properly diagnose a patient’s condition and recommend a treatment plan.

Ultrasound in the ED brings light

Robert J. Tillotson, DO, chairman and medical director of the ED at St. Michael’s Hospital in Stevens Point, Wis., defines the introduction of ultrasound into the emergency department as “coming out of the darkness,” giving him “eyes to see inside the body.” Ultrasound systems provide ED physicians with the ability to make better informed treatment decisions for patients, he says. “Being able to use ultrasound at the bedside, right at the point of care to make decisions, has changed the way we practice medicine,” he says.

St. Michael’s ED, which treats about 39,000 patients annually, is on its third generation of ultrasound systems. The facility started with a large, standalone machine, moved to a portable laptop, and now, has been using Zonare’s convertible ultrasound system since the latter half of 2005. Tillotson says that is it has the advantage of a large screen, along with a compact size, while maintaining superior image quality.

He presents an example of why the use of emergency ultrasound is important. A woman presents with vaginal bleeding, terrified that she is having a miscarriage. Ultrasound allows the ED physician to see if the pregnancy is ectopic or if it is in uterus, and if there is a heartbeat. Prior to having ultrasound devices in the ED, the process of diagnosis could take several hours, depending on the time of admission, Tillotson says. From the time the patient’s name is typed into the system to diagnosis takes 10 minutes. 

“Therefore, a two-and-half-hour visit may turn into a 15 minute visit, and she can leave with a picture of her baby,” Tillotson explains. “In addition to improving patient throughput, it also improves patient experience, as she can be assured of a diagnosis sooner.”

Pregnancy concerns and abdomen pain are the most common conditions for which ultrasound is used in St. Michael’s ED. It’s also used to examine patients with cardiac ailments, ocular, musculoskeletal issues and abscesses. Tillotson adds that in a typical shift, he utilizes ultrasound about six or seven times.

For physicans in the emergency department at Massachusetts General Hospital (MGH) in Boston, ultrasound is a tool to examine trauma patients to identify life-threatening causes of hypertension and routine procedure guidance like abscess drainage, central or peripheral line placement or para- and thoracentesis, according to Vicki E. Noble, MD, director of emergency ultrasound.

Compact systems, including several SonoSite systems and a Siemens Healthcare compact Acuson P10, provide the needed flexibility. Each week, about 50 FAST (Focused Assessment with Sonography in Trauma) exams and 15 focused cardiac ultrasounds are performed. Noble notes that the ever-improving image quality on these smaller, more portable machines has made this technology more accessible.

Some rads hesitate to accept emergency ultrasound

Tillotson suggests that radiologists have questioned the skill of ED physicians using ultrasound as a “ploy to keep their silo intact.” He says that while the radiologists at St. Michael’s were initially hesitant, “we now work together very well, specifically because we save the ultrasound technologists a lot of late-night trips to the hospital.”

Currently, emergency medicine ultrasound reimbursement is based on limited studies, whereas radiology can bill for complete studies. Tillotson notes that his ED has yet to bill for ultrasound, but adds that they are going to begin that process in order to receive the reimbursement funds to keep their equipment updated.

“A complete study, as defined by the CPT, is one in which an attempt is made to visualize and diagnostically evaluate all of the major structures within the anatomic description,” according to