Using 3D and 4D imaging and reconstuction on the Toshiba Aplio XG, physicians at Spectrum Health in Grand Rapids, Mich., can obtain axial images that can’t be imaged using probes.

Fully featured systems about the size of a laptop computer combined with ever-increasing image quality are putting ultrasound on a bit of a pedestal. From ob/gyn to emergency care, clinicians are appreciating the return on a much smaller investment and looking for more areas in which to expand with ultrasound.

Working in the busy emergency department at High-land General Hospital in Oakland, Calif., Daniel D. Price, MD, director of the Emergency Ultrasound Fellowship and emergency physician, uses the SonoMB from Sono-Site for a growing variety and number of procedures.

“It’s a real advance,” he says. “It bumps up the image quality and really makes a difference, especially with vascular access for central venous catheterization.” Vessel edges stand out more clearly for catheterization and when putting in a femoral line. Price can more easily differentiate the vessels from surrounding soft tissue —important when every minute might count for that patient. “If you get a good-quality image, you can proceed directly with the procedure,” he points out. “You don’t have to spend several minutes interrogating the structure.”


Ultrasound flourishes

Price also uses the equipment for performing nerve blocks—the area in which he sees the biggest improvement for portable ultrasound. “The nerves almost jump out of the screen at you.”

Another procedure is ultrasound guidance for arthrocentesis, a procedure in which a needle is inserted into a joint to extract a fluid sample.

Aside from making it easier for Price and his colleagues to perform these procedures themselves, the hospital offers a fellowship in ultrasound. “We teach residents and medical students, so it’s helpful to show them procedures with clear images.”

“We’re not radiologists and we don’t have $200,000 ultrasound machines,” Price says. “But we’re getting that image quality. There are more and more uses for ultrasound and higher end technologies such as spectral Doppler and multibeam technology. We can now get these technologies in smaller units that are ruggedized and can withstand the demands of the ED. All of this has allowed ultrasound to flourish in our specialty.”

However, as technology in small packages improves, manufacturers must keep the user interface as simple and intuitive as possible, he says. “We’re typically teaching new users, who are learning new skills and techniques, so it needs to be simple and quick. It can’t take two minutes for a machine to boot up.”


Portable power

Mark Jundanian, MD, chairman of the radiology department at Saint Anthony Hospital in Chicago has two portable ultrasound units from Zonare. One goes out to clinics, while the other is used for studies around the hospital.

The hospital purchased the portable units from Zonare because they started an experimental relationship with three clinics and didn’t want to invest in new equipment for new customers, he says. The portable units work with rolling carts that attach them to a larger, higher quality screen and keyboard. Additional carts are left at the clinics so the technologist just has to travel with the engine portion and plug it into the cart. Then, he or she takes that engine back to the hospital and sends the images to the PACS. “Small, highly capable units have opened the door to this kind of service,” says Jundanian. Before getting the portable units, a mainframe ultrasound machine was transported to clinics on a truck and lowered with a liftgate, pushed across rough pavement and so on. “It was really much harder than this plan.”

Aside from the downsizing of the equipment, Jundanian says image quality has improved dramatically in part due to transducer design and how the data are recovered and processed. “There have been very significant improvements in the quality of the image,” he says, such as “the ability to discern two different tissues adjacent to each other and see a lesion in the liver as different from the liver.”

Although Jundanian had the techs play the biggest role in selecting portable ultrasound equipment since they use it every day, he uses the equipment about once a week himself. “It’s very intuitive. If I’m doing a procedure, I’m using ultrasound as a tool. I’m using it as a flashlight to find something. I don’t want to spend a lot of time setting up the equipment and being a sonographer.”

Janet Horenstein, MD, an ob/gyn in the Department of Obstetrics and Gynecology, University of Southern California School of Medicine in Los Angeles, has found 3D ultrasound imaging equipment from Medison to be helpful. “You can evaluate different anatomical structures and abnormalities better.” She also can get a dataset of images and manipulate them later so there’s no waiting for the patient.


3D baby boom

Although more and more expecting parents want 3D images of their unborn babies, Horenstein says what the modality really allows is an easier way to explain abnormalities to patients. “It’s hard for them to imagine [some fetal abnormalities], but with 3D imaging, I can show it to [the mother] better.” She also has found 3D ultrasound beneficial when working with patients who do not have a problem with their pregnancy. For example, a mother might have a history of cleft lip in her babies. If everything is developing normally, Horenstein can show her a picture of her baby with a clean lip and palate.

3D images of babies help with patient satisfaction at Spectrum Health, a seven-hospital system based in Grand Rapids, Mich., says Sue Camp, imaging applications coordinator.

As a long-term Toshiba user, Camp set up training and a demo of the Toshiba equipment. The sonographers and radiologists were impressed and ultimately the decision to buy was made by them. She says the physicians are very impressed with the Aplio XG from Toshiba America Medical Systems. With 3D and 4D imaging and reconstruction, they can obtain axial images that can’t be imaged using probes. “That defines a lot that determines diagnosis and treatment,” she says, particularly when imaging the uterus and endometrial area, cysts on ovaries and fallopian tube abnormalities.

Aside from obstetrical and abdominal work, Camp plans to use the equipment for vascular studies as well. “The potential is there and we’re still finding our ways and tweaking it. There really needs to be dedicated applications time—solely doing vascular exams and tweaking the different variables.”


What’s next?

“I’m disappointed that 3D hasn’t come further by now,” says Camp, although she admits that she hasn’t yet seen the software changes made over the past year. But since 3D technology is all about manipulation and reconstruction, it needs to be as automated as possible or it doesn’t get used. Easy, more automated 3D and 4D technology is really the key.

Price is experimenting with 3D ultrasound to determine where it can be most helpful. “I work at a trauma center so it’s useful for extracting foreign bodies, such as bullets, and in difficult situations to get a needle in a vein or artery,” he says. “We’re also looking to see if 3D is helpful for arthrocentesis. 3D is sexy but its uses are probably more limited than we’d like them to be. We need to see where it’s really helpful.”