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Handheld Ultrasound Trends.

Prehospital Ultrasound in Emergency Medicine: Think Outside the 4 Walls

In cardiac care, mere minutes matter. That's why some medical specialists today may be turning to prehospital ultrasound to accelerate treatment, ensuring patients receive life-saving therapies faster.

In the hands of paramedics and other emergency services providers, handheld ultrasound devices, such as GE's Vscan Extend™, may obtain cardiac images sufficient enough for interpretation even before patients arrive in the emergency department. With proper training, prehospital clinicians can not only use ultrasound to identify a problem, but also to help triage patients.

Benefits of Prehospital Use
Point-of-care ultrasound (PoCUS) has already been shown to potentially help diagnose a plethora of life-threatening conditions, such as hemoperitoneum, pericardial effusion, cardiac tamponade, pneumothorax and abdominal aortic aneurysm. Prehospital ultrasound can also identify situations where resuscitative efforts could be beneficial and should be continued. Putting those diagnostic capabilities to use en route to a hospital may save more lives.

For example, according to investigators in a World Journal of Emergency Medicine study, PoCUS education for paramedics can be helpful to patients: "Our pilot study suggests that with minimal training, paramedics can use [ultrasound] to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill."

An American Journal of Emergency Medicine editorial also discussed the importance of using prehospital ultrasound in situations with critical patients.

"Streamlined [focused assessment with sonography for trauma] may increase triage accuracy of blunt torso trauma patients in mass casualty incidents with limited medical resources," the authors noted. "We recommend the use of [streamlined focused assessment with sonography for trauma] to decrease patient triage to treatment time in any unfortunate future disasters."

In many instances, prehospital clinicians are the first to interact with critically ill patients. Consequently, having PoCUS available to provide real-time internal images may provide significant benefits to both cardiac life support and advance trauma support. Not only may it assist with any prehospital decision-making, but it may also help inform how physicians proceed once patients arrive in the emergency department.

Real-World Implementation
Prehospital ultrasound offers a real-world option in helping to provide immediate care to patients in acute situations. Using GE Vscan Extend™, a helicopter paramedic unit in New Zealand screened airlifted patients for potential cardiac problems prior to landing at Dunedin Hospital, which is located in an area where road travel can be precarious.

In these and other frenetic conditions, PoCUS is helpful because paramedics may clearly see heart function. With ultrasound, New Zealand's paramedics assessed cardiac activity and checked for internal bleeding, thoracic injuries and pulmonary embolisms. They also used handheld ultrasound to side-step unnecessary procedures. For example, PoCUS use determined a suspected pneumothorax in one patient did not exist, so paramedics opted not to decompress the chest.

Prehospital ultrasound may also be used to triage patients who should be taken immediately to the operating room. Doing so saves valuable time otherwise spent running further diagnostic tests in the emergency department.

PoCUS Training
Handheld ultrasound can be a valuable tool for nearly any healthcare provider who receives proper training. Paramedics and other prehospital clinicians may achieve the same level of skill as physician sonographers if they undergo comparable instruction.

This level of accuracy may alter and positively impact the care a patient receives upon arriving at the hospital by giving physicians insight into a patient's condition.

While research into the use of prehospital ultrasound is in the early phases, study results and real-world implementation have already shown it may play a vital role in time-sensitive, critical conditions. All in all, proper use may decrease both mortality and morbidity, improving overall patient outcomes.
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Handheld Ultrasound Education.

How Handheld Cardiac Ultrasound Aids in Diagnosis

Handheld cardiac ultrasound does not aim to replace routine comprehensive echocardiography, but its use may decrease the frequency of comprehensive scans. As a result, it might not only make clinicians' lives easier, but it may also lead to better patient experiences and outcomes.

Making a Cardiology Diagnosis
There are many applications for handheld ultrasound in making a cardiology diagnosis. For example, it may be used specifically to assess cardiac chamber size and function and valvular regurgitation. An article in Clinical Cardiology reported that "the pocket-sized [portable transthoracic echo (pTTE)] provides accurate detection of cardiac structural and functional abnormalities beyond the [electrocardiogram (ECG)]. In addition, the use of pTTE as an initial screening tool prior to [standard TTE] is cost-effective, suggesting that the pocket-sized pTTE is poised to alter the current diagnostic strategy in clinical practice."

Non-cardiologists may use handheld ultrasound as a tool for aortic stenosis and mitral regurgitation. This means that the ultrasound may be an adjunct to clinical examination in patients where a murmur is heard. Wiener Klinische Wochenschrift reports, "Pocket-size ultrasound imaging devices without continuous and pulse wave Doppler modalities can, even in the hands of a non-cardiologist with limited cardiac ultrasound instructions with high sensitivity and specificity, be a useful tool for detecting more than mild aortic stenosis and more than mild mitral regurgitation."

Handheld ultrasound may also be used to assess the volume status of the patient, via the inferior vena cava (IVC) diameter, as an indicator of progression of heart failure. As discussed in the American Journal of Cardiology, this use of ultrasound "is associated with an increased risk of heart failure admission and may provide clinically useful information at the point of care to guide heart failure management."

Augmenting Workflow
Handheld ultrasound may be used by primary care physicians to detect cardiovascular disease, and this may decrease the number of unnecessary formal echocardiograms. One study, published in Heart, used remote expert support to help interpret the handheld ultrasound images and found it to be "rapid and useful for detecting significant echocardiographic abnormalities and reducing the number of unnecessary echocardiographic studies."

Having repeat formal transthoracic echocardiograms (TTEs) to detect problems such as impaired ventricular function, pericardial effusion and IVC collapse is common. Using handheld, focused ultrasound scans of the heart may reduce the need for so many follow-up TTEs in a short space of time. A paper in the Journal of the American Society of Echocardiography concluded that "[t]he judicious use of expert focused cardiac ultrasound in place of repeat inpatient TTE has the potential to deliver quality cardiac imaging at reduced cost."

In some patients who are acutely unwell, moving them into a good position in their bed for a formal echocardiogram could be challenging. Handheld ultrasound may have an advantage as it can be used on patients in a semi-recumbent position. An article in Acta Anaesthesiologica Scandinavia concluded that "[t]he apparatus is well-suited for performing a [focus-assessed transthoracic echocardiography] examination in a one-day surgery setting and could very well also be applicable in almost any situation involving patients with acute illness."

Streamlining Care
What's more, handheld ultrasound may be used by cardiologists on their ward rounds. Being able to do a bedside ultrasound may reduce the number of formal echo studies that need to be done. As described in the American Journal of Medicine, "For hospitalized patients, [t]his finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies."

In emergency departments, handheld ultrasound may reduce the time to diagnosis in patients presenting with shortness of breath. Herz reported, "One-third of patients had significant findings on the scans to possibly aid diagnosis and prevent misdiagnosis. This has the potential to reduce time to diagnosis in the [emergency department]."

Handheld ultrasound may be used by a broad range of healthcare professionals in different specialties to help streamline patient care, improve diagnosis and direct therapy — and it might be a beneficial adjunct to formal echocardiography.
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Handheld Ultrasound Practice Areas.

How a Handheld Ultrasound Exam Could Help in Three Scenarios

The handheld ultrasound exam offers incredible potential for today's primary care physicians (PCPs) — it can, and should, be used as a key diagnostic tool. According to a study in The World Book of Family Medicine, "Ultrasonography should be a diagnosis tool beside the stethoscope in the general practitioner office ... the two instruments should be considered as complementary."

Further, a study in PLoS One identified that "after a simple and short training course, a pocket-sized ultrasound device examination can be used in addition to a physical examination to improve the answer to ... common clinical questions concerning in- and outpatients and can reduce the need for further testing."

Specifically, a focused ultrasound exam may be used to complement the PCP's physical examination in three common diagnostic areas: right upper quadrant pain; flank pain; and deep vein thrombosis (DVT).

Right Upper Quadrant Pain
Right upper quadrant pain is a common presentation in primary care. The handheld ultrasound exam of the right upper quadrant of the abdomen can look for signs of gross abnormalities of the liver and gallbladder.

Point of care ultrasound may be used to identify the presence of gallstones and to assess for acute cholecystitis by detecting Murphy sign, anterior gallbladder wall thickening and pericholecystic fluid. The handheld ultrasound may also be used to assess potential bile obstruction by measuring the common bile duct diameter. This may help the physician pursue non-gallbladder sources of epigastric discomfort.

Flank Pain
When it comes to flank pain, a handheld ultrasound device may be used to assess the kidneys and, specifically, to look for hydronephrosis, identify renal or ureteral stones and to check the post-void residual bladder volume. This may provide a physician with more context in relation to the physical exam.

A study in Urology noted that a urologist "using handheld-pocket-size device is equivalent to a sonographist-performed ultrasound study using a standard device in most parameters examined. The handheld device can be used in evaluating the upper and lower urinary tract with the exception of renal masses and therefore can be of great assistance in a wide variety of the daily urological practice scenarios."

Deep Vein Thrombosis
There is a potential benefit in using handheld ultrasound devices when dealing with DVT. According to the Journal of the American College of Cardiology: Cardiovascular Imaging, "The accurate and immediate decision-making allowed by the pocket-size ultrasound examination (PUE) has the potential to exert a significant impact on the current diagnostic strategies for DVT. Positive PUE can make other diagnostic or therapeutic procedures available earlier for the patient without standard ultrasound examination."

Handheld ultrasound devices can potentially allow physicians to scan anyone suspected of having DVT without them having to wait for blood test results. A paper in Thrombus stated that "reducing the time to diagnose DVT could potentially avoid the use of self-injected low molecular weight heparin by patients."

Training for Success
As with any technology, getting the proper training is a key component for reaching positive results. An article in the Annals of Internal Medicine encourages "residency training programs to teach PoCUS, practicing hospitalists to incorporate it into daily practice, and hospitals and hospital medicine programs to provide easy access to the necessary technology."

A study in BMC Medical Education concluded that "medical students with minimal training were able to use (a pocket-size imaging device) as a supplement to standard physical examination and successfully acquire acceptable relevant organ images for presentation and correctly interpret these with great accuracy." And, according to the Annals of Internal Medicine study, the "use of ultrasound by hospitalists will continue to modernize the bedside evaluation and streamline the diagnostic process."

By adding handheld ultrasound to the routine examination, PCPs may have the potential to reduce waiting times and ultimately deliver better care to those who need it.
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Handheld Ultrasound Education. Improving Patient Care.

Handheld Point-of-Care Ultrasound: Why Having it is Important

When it comes to the best quality patient care, the physical exam is a fundamental factor. Providers glean a great deal of information this way, but using handheld ultrasound to visualize non-visible parts of the body might be a powerful clinical complement.

In many cases, having handheld ultrasound available might also be the key to accelerated patient care and accurate diagnoses. And, when time is of the essence, point-of-care ultrasound (PoCUS) may be the tool that speeds up your diagnostic capabilities.

Ultimately, using PoCUS, such as GE's Vscan Extend™, increases not only your confidence with your diagnosis, but your patient's comfort with the care you provide.

Inspiring Confidence
When a patient presents with a suspected problem, such as right upper quadrant or flank pain, making a timely diagnosis may be critical. Alongside a physical exam, PoCUS lets you focus immediately on the problem area and see what's invisible to the naked eye, giving you greater confidence in identifying the cause of the symptoms.

In fact, point-of-care ultrasound could increase how detailed your exam can be, adding valuable information to the patient's electronic health record. In a short amount of time, PoCUS may capture multiple clear images to give you a more robust picture. According to the concluding findings of a 2016 report from The World Book of Family Medicine, "because of a significant number of advantages, ultrasonography should be a diagnosis tool" used with a stethoscope in medical offices.

If needed, this level of detail lets you refer your patients for the right test or diagnostic treatment, reducing the likelihood they will go through unnecessary doctor visits or unneeded additional imaging.

Saving Time
PoCUS images may also help you save time whether you're an emergency department (ED) physician or a general practitioner.

In the ED, having access to a handheld ultrasound device may determine if and how you triage your patients. For example, if an individual has symptoms of cardiac distress, PoCUS may reveal information at the bedside in real time.

A PoCUS exam may also pave the way for rapid diagnosis during a regular doctor's visit. During an appointment, you may make an immediate decision whether your patient needs to see a specialist or be hospitalized. Not having to wait for another provider's analysis may fast-track needed therapy and reduce any stress patients might have about their symptoms.

Shortening Diagnosis Time
As you use PoCUS more often and fine-tune your skills, you're likely to become more confident in your findings. Over time, it's possible that you'll be able to render your bedside diagnoses and offer guidance more quickly.

A 2011 European Journal of Echocardiography study tested the diagnostic efficiency of PoCUS and high-end echocardiography and concluded that "pocket-sized echocardiographic examinations of approximately four-minute length, performed at the bedside by experts, offers reliable assessment of cardiac structures, the pleural space and the large abdominal vessels."

Improving Relationships
As a hand-held device, PoCUS gives you the opportunity to have more face time with your patients. In many cases, they watch as you conduct the exams and can ask questions. Getting real-time information from ultrasound images may increase the patient's confidence in your diagnosis and the treatment you'll prescribe. For example, PoCUS at the bedside may provide a pregnant woman with the immediate visual confirmation that her unborn baby is healthy.

Additionally, according to a 2018 Annals of Internal Medicine study, PoCUS may also offer high ultrasound imaging quality, and the authors concluded that they "believe that use of ultrasound by hospitalists will continue to modernize the bedside evaluation and streamline the diagnostic process." Bedside testing may lead to decreased lengths of stay, a reduction in resource utilization and lower costs.

PoCUS vs. Other Modalities
In many instances, PoCUS may provide better ultrasound image quality than the other modalities you employ with your patients. For example, according to the conclusions of a 2013 Clinical Cardiology study, "the pocket-sized (portable transthoracic echocardiography) provides accurate detection of cardiac structural and functional abnormalities beyond the ECG." These findings may boost your confidence that you'll catch a problem earlier.

In addition, research has also shown PoCUS is a strong alternative to chest X-ray when diagnosing pericardial (PE) and pleural effusions (PLE). A 2015 Scandanavian Cardiovascular Journal article that observed nurses using ultrasound concluded that "Cardiac nurses were able to obtain reliable measurements and quantification of both PE and PLE bedside by focused ultrasound."

Overall, in today's healthcare environment, PoCUS may play a significant role in providing additional clues during physical exams to make a diagnosis. By employing PoCUS, you may be able to gather these images much faster than you possibly could with other options. And, as you become more proficient with the hand-held technology, you may become more confident with your real-time diagnosis, potentially improving patient care.

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Technology and Innovation. Handheld Ultrasound Practice Areas.

Building the Doctor-Patient Relationship With Practical Visualization Tools

The doctor-patient relationship relies on strong communication, just like every other relationship in healthcare. Between providers, communication failure, not a lack of provider skill, has been identified as the root cause of approximately 80 percent of serious adverse events in healthcare settings. The implications of failures in doctor-patient communications should be taken just as seriously.

Medical schools are stepping up to the plate and putting more emphasis on relationships and communication, but more practical steps are needed. Thankfully, a new class of portable tools is emerging to address those gaps.

Better Outcomes Start With Physician Empowerment
Often, the discussion around outcome improvement centers on patient empowerment. Of course, patient-centered health matters, but a large portion of it rests in the hands of physicians.

Physicians have an amazing opportunity to be catalysts in revolutionizing the patient experience, simply by being willing and enthusiastic agents of patient empowerment.

At the same time, the benefits of an improved doctor-patient relationship flow both ways. Having confused, irritated patients might lead to poor outcomes, which may directly impact a physician's feelings of job fulfillment — a dynamic that can't be ignored as we face the public health crisis of physician burnout.
 
Technology That's Improving the Doctor-Patient Relationship
The relationship between doctors and patients is dynamic and relies on direct communication. However, it's also filtered through the overall patient experience. Breakthroughs in technology have been made that not only improve care, but also open up new channels of communication for physicians.

Advances in digital devices allow 4D ultrasound allow doctors to not only share digital images almost immediately with expectant parents with one click, but also enable instantaneous collaboration with other clinicians in addressing any issues. The cloud-based system Tricefy™ allows immediate commentary from physicians and facilitates dialog from practically anywhere.

Enhancing clinical relationships requires not only better communication skills, but also tools that close the gap between diagnosis and patient understanding through a more educational and interactive experience. Patients can not only see what their doctors see, but also get more precise information, like the exact location of an issue. This is where portable technology, such as handheld ultrasound, gives teeth to initiatives attempting to improve the doctor-patient relationship.

Understanding the Power of Handheld Ultrasound
Handheld ultrasound has led the way to a new level of accessibility for providers, with some units being the size of a smartphone, while still providing quality images. According to the conclusion of a study published in The Acta Anaesthesiologica Scandinavica that compared the Vscan and the Vivid-i systems, "the Vscan displays image quality interchangeable with larger and more expensive systems. The apparatus is well-suited for performing a (focus-assessed transthoracic echocardiography) examination in a one-day surgery setting and could very well also be applicable in almost any situation involving patients with acute illness."

The simple nature of their portability can help doctors at the bedside, as well. Authors of a study published in The Annals of Internal Medicine concluded "that the use of ultrasound by hospitalists will continue to modernize the bedside evaluation and streamline the diagnostic process."

Consider the fact that the use of pocket mobile ultrasound devices (PUDs) has been found to actually spare patients the negative and often costly experience of unnecessary exams. According to a study published in PLOS One, "after a simple and short training course, a PUD examination can be used in addition to a physical examination to improve the answer to 10 common clinical questions concerning in- and outpatients, and can reduce the need for further testing."

Clinical settings, though, are just the beginning. Organizations such as Doctors To You are meeting patients where they are and leveraging technology like Vscan Extend™ to expand the reach of house calls. We're also entering a period where more employers are offering healthcare services in the workplace. Companies including Disney, Apple, Boeing, Cisco and Goldman Sachs now provide on-site clinics for their employees, further increasing the potential for portability and accessibility in diagnostic modalities like handheld ultrasound, and opening up an entirely new venue for the doctor-patient relationship.

Initiatives around improving outcomes and the patient experience can easily remain abstract without serious discussions about the technology that pulls them into clinical realities. Forward-thinking healthcare leaders should keep an eye out for developments like handheld ultrasound as foundational tools in improving doctor-patient communications.
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