Sound Decision-Making: Ultrasound Finds Its Place in Every Forum
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 the American College of Emergency Physicians (ACEP) 2007 “Emergency Ultrasound Coding and Reimbursement Update,” written by Stephen Hoffenberg, MD, and Jessica Goldstein, MD. “A limited study would address only a single quadrant, a single diagnostic problem or might be a follow-up examination.”

However, Tillotson suggests that there is “a lot of literature that suggests we can be equally effective to radiologists,” particular for conditions like deep vein thrombosis (DVT).

In fact, Burnside et al found that emergency physician-performed ultrasonography may be accurate for the diagnosis of DVT compared with radiology-performed ultrasound, according to a systematic review published in the June 2008 issue of Progressive Clinical Practice.

Noble makes the distinction that in the radiology department, the individual who reads the studies is not tasked with treating the patient, and does not use the images to guide treatment at the point of care. “The difference is that the ED physician uses ultrasound to direct treatment and further testing more efficiently but guiding his or her clinical impression of what is wrong with the patient,” she says. Noble adds that other specialties also have begun widespread use of ultrasound and that some, like urology and OB/GYN, have been doing this for some time. “Especially now that the devices have dropped in price and the machines have an easier user interface, more clinicians feel comfortable with the technology.”

Also, Tillotson says that quality assurance methods should be built into every program. “The question remains, ‘can ED physicians do it well?’ I will suggest that we are saving lives by assuring that these patients receive quicker access to care,” he says.

However, the use of compact equipment concerns some radiologists, including Hisham A. Tchelepi, MD, associate professor and director of ultrasound at Wake Forest University in Winston-Salem, N.C. “If you want to use ultrasound to make a diagnosis, you have to use very high-end equipment,” he says. He cautions making a diagnosis on smaller portable laptops due to their resolution, and inferior hardware and software.

However, Tchelepi notes that smaller ultrasound systems can be effective in the ED or in the interventional suite to find venous access, check for ascites or pleural effusions. “In our department, we perform detailed ultrasound exams. Many times we identify lesions that are not clinically expected which would trigger further imaging with CT or MRI many of those are small or even subtle lesions, for that reason you really need a high-end machine,” he notes.

Noble adds that the radiologists and ED clinicians are not performing the same tests for the same purposes. Therefore, the high-end diagnostic quality of the more advanced machines is not always necessary, because “in the ED, we are not seeking to do comprehensive diagnostic imaging,” she says. “We are attempting to make clinical decisions at the point of care, and the smaller devices have allowed us to expedite those treatment decisions.”

“There is no question that radiologists perform a more thorough study with more detail,” Noble says. “But, these smaller, less expensive machines allow the ED physicians to provide safer, more accurate diagnostic testing and to do it more quickly both of which will be cheaper for the patient and for the hospital in the long run. For example, sometimes, I simply need to know if a patient is hemorrhaging, because if so, I need to call a surgeon—that simple ‘yes or no’ question can be obtained quickly with the new devices,” she explains.

“As a radiologist, I worry that everyone is trying to embark on the field of ultrasound—in office settings, in the ED, and even in the operating room,” Tchelepi says. “There have often been instances when a patient has been sent home after being imaged in the ED, only to return to the radiology department—at which time, we find complications which are sometimes life-threatening. I am not against ED physicians using ultrasound machines, but that shouldn’t be the end of the patient’s treatment.” He adds that those patients follow up with the radiology department, which does not always happen when the patient’s are assessed in the ED.

Each of the physicians acknowledge that that the turf battle is growing, and for many, the motivation appears to be financial.

Fusing ultrasound with other images

In November, Wake Forest University deployed GE Healthcare’s Logiq E9 with fusion imaging which “assists with the management of much more complicated cases which occur with marked frequency,” Tchelepi says. 

He explains that many patients who have kidney failure, and therefore cannot have contrast administered for the CT scan are referred for ultrasound for further evaluation. “On the CT scan, we frequently notice some cystic lesions, which cannot be defined as simple cysts by CT remain problematic with conventional ultrasound. Specifically, if the patient has more than one cyst, a cyst in question becomes difficult to identify,” Tchelepi notes. “With this technology, we can simply download the CT scan, fuse it with ultrasound images and accurately pinpoint a suspicious cyst and further characterize it.”

“We see a large number of cancer patients—many of these patients will have tiny liver lesions [about 3-4mm] on the CT scan image, but those lesions cannot be characterized on CT because they could either be cysts or metastatic cancer,” Tchelepi says. He notes that fusion imaging allows trained radiologists and technologists to fuse the CT or MR image to an ultrasound image, and based on anatomy line marks, can pinpoint them, for potential biopsy.

This technology is most applicable in oncology. Specifically, Tchelepi predicts that it will most likely thrive in the interventional ultrasound suite for biopsies.

Ultrasound fusion imaging has the potential to change the way we perceive ultrasound images, according to Tchelepi. He exemplifies a patient who presents with liver lesions. “First, you read the initial CT image at the PACS workstation, then you transfer from the reading room to the ultrasound room or the procedure room. However small that gap in time, it may cause a disruption in the process. Now, when these images are fused at the ultrasound machine, the radiologist can bring areas of concern seen on the MRI or CT to the ultrasound field of view, mark them and then proceed with the procedure,” he explains. “With this technology, liver lesions that are well seen on CT or MRI and we were unable to identify with conventional ultrasound without fusion were simply outside of the ultrasound field of view, obscured by shadowing from ribs.”

“This technique is helping us look at ultrasound from a different perspective, and once it popular and standardized, could change the role of ultrasound, and potentially change the way procedures, such as biopsies,” Tchelepi concludes.

The future stands subject to innovation

The current field of ultrasound is ever-changing due to rapid technological progression, according to Noble. “Ultrasound’s role will continue to evolve, as long as the technology keeps changing,” she concludes. “At some point these devices may be able to perform some interpretations automatically.  This and other innovative pipeline techniques will continue to push the envelope of this field.”