The implementation of ultrasound has evolved considerably from when I started performing them back in 1996, with a mechanical probe and the mental “imaginoscope” necessary to interpret images and respective pathology. Today’s technology offers a vast array of image quality advancements, workflows, and techniques. These machines have competitive factors that play a role in any ultrasound implementation on any given patient. Moreover, ultrasound has become extremely available in clinics. This article will address all the common and not-so-common pitfalls regarding ultrasound machine selection, education, technological workflow, and veterinary culture influences, Basically, the key issues associated with clinical sonography from the time of clinical presentation to outcome for any give sick patient and they all influence the cost of missing a lesion. Machine selection Ultrasound machines are the last thing to cut corners on when considering capital equipment purchases in veterinary medicine. Sonography is a heavily user-dependent modality as we convert veterinarians and technicians into sonographers in a much shorter amount of time compared to human sonographer counterparts. For this reason, ultrasound machine selection and optimization are even more curial in veterinary compared to human sonography. Plan to spend around $35,000 to $50,000, or even more, for an ultrasound machine to do full-body scanning. This may sound daunting at first, but we are talking about clinical sonography that would cover every point in the abdomen or heart/chest images in all body types. This price range (probe configuration is the largest variable here), if priced conscientiously with respect to the quality and clinical support of the machine, should buy you image resolution to define curvilinear patterns and contrasting tissue presentations, adequate acoustic power to penetrate tissues, adequate probes with frequencies and resolutions for every presentation, work-flow optimization, optimized screen size and resolution, and consistent transmissibility of image sets in proper contained file size with minimal steps. These factors vary greatly by manufacturer, so it is in your, and your sonographer’s best interests to test all these factors on multiple machines on a variety of patient sizes, conformations, and body scores with clinically tested presets for each setting. If you are not optimizing these factors, you risk missing lesions, struggling to find structures such as the common bile duct and right adrenal, missing steps in the telemedicine transmission, and having to repeat transmission or encounter erroneously large files caused by software glitches that have not been addressed by the manufacturer or the distributor. These factors cause loss of time, which is inherent economic loss with every case. Your imaging report is your calling card, so do it right and ensure your image is enhanced by your optimized machine purchase first. On sonographers The sonographer title behind the probe discussion comes up frequently in our clinical sonography circles. Do we need a specialist or veterinarian to perform solid consistent image acquisition? Remember, image acquisition and image interpretation are two vastly different concepts. Interpretation depends on optimal complete image acquisition and the title matters little in this regard if the drive and the ability to learn to perform an optimized and complete image set, whether normal or abnormal presentations are in play, is inherent in the novice sonographer. We, as interpreting specialists, see this all the time every day. over hundreds of cases. Optimal image sets come in from all types of sonographers with various professional titles, as well as suboptimal image sets that need further support and instruction. We have a long history of various results with GP sonographers and, of course, specialists performing ultrasound. However, the relatively new technician model works well in veterinary clinical sonography as it has in human for over 30 years. However, the teaching/learning approach differs significantly with high-level imaging needing to be obtained in short time frames largely without the ancillary studies in physics and image optimization that the human medicine registered diagnostic medical sonographer (RDMS) counterpart endures in his/her program. Regardless, our recent double-blinded study has shown technicians, veterinarians, and specialists can have similar image quality results when trained appropriately.1 Education Choose the educational venue best for you, your workflow, and your goals. Which program will get you up to speed the fastest allowing you to image an abdomen or heart in 15 minutes or less without missing pathology? With practice, focus, and drive it really shouldn’t take you longer than 15 minutes. You can train yourself toward 10 or even less than five minutes with emergency-oriented techniques maximizing the technology of the ultrasound units currently in the market. Consider your local mobile sonographer or best sonographer in your practice. At some point in the past, yours truly included, we all started somewhere wondering if the bladder had a stone when it was just hard stool in the colon superimposing upon an overdistended bladder. We have all made every mistake possible and have learned from every one of them if we were conscientious about each error. The technology of today, along with solid persistent education and effort, allows you to achieve these goals. Then do the math on efficient clinical outcomes as well as economic ones. Telemedicine It is extremely rare to scan perfectly after a single educational seminar, and there are vast levels of ability to interpret ultrasound image sets. Therefore, you need support from the company that interprets the images, and a scanning protocol that will work to your benefit. Regarding interpreting specialists available in veterinary medicine, the recent American College of Veterinary Radiology (ACVR) and European College of Veterinary Diagnostic Imaging (ECVDI) abdominal ultrasound standardization states, “Interpretation at the time of the examination being performed by a board-certified veterinary radiologist is therefore considered to be the gold standard.”1 Sonographers and referring veterinarians will find rapidly this is not, and will never be, possible owing to the lack of radiologists available to read sonograms compared to the increasingly vast number of ultrasound image sets being created and sent to telemedicine companies or those for in-house review. The good thing is that many American Veterinary Medical Association (AVMA)-recognized boarded specialists that have many years of experience in clinical sonography are available to interpret image sets with an approach and emphasis on their specialty such as American College of Veterinary Internal Medicine (ACVIM), American Board of Veterinary Practitioners (ABVP), Veterinary Emergency and Critical Care Society (VECCS), as well as other accredited specialties that have clinical sonography incorporated into their functional disciplines. With this specialist spectrum of availability, the sonographer and referring clinician can select which type of perspective and interpretation to have: Radiology Internal medicine Internal medicine and surgery Emergency and critical care Screen size and resolution Take into consideration screen resolution and screen size. You should position yourself about an arm’s length away from the screen. If you are trained to find adrenal glands and you are testing out a machine, a feline or canine adrenal should jump on the screen. You should not have to squint to look at it. Squint during the trial? You will squint for the life of the machine. Consider 15- to 18-in. monitor screens and at least 1920 x 1080 resolution if possible. Every little technological factor in your favor adds up in image quality and these two factors are very often under considered in purchases. Ultrasound knobology and workflow I personally despise touch screens as it is too easy to make errors, and digital workflow is tedious and frustrating in my hands; when I can feel a keyboard, I can move across knobology workflows faster. Maybe you like touch screens and your brain and fingers work differently than mine, which is fine. Do what works best for you. But ask yourself, how much time does the knobology of the machine take you? Compare machines on knobology workflow. Knobology workflow is an often-overlooked concept, but one that is inherent in the time elapsed on every scan and should feel fairly seamless after a handful of cases. Time your knobology workflow and compare with each unit. How many steps does it take you to get through your case? When there is poorly designed knobology, you feel like your fingers are doing a bad ballroom or line dance where you are always a step or two behind and bumping into someone or stepping on toes. Personal experience in both sonography and short-lived ballroom and line dancing experience aside, all I can say is poor knobology workflows translate into time lost and frustration gained. Image transmission Given image quality is paramount, you must spend adequately to run with a machine that is going to be viable day in and day out—from a thin ferret to an overweight Rottweiler; from an abdomen to heart to thyroid to stifle cruciate. You want a machine capable of high resolution and has a rapid workflow that can move a 30- to 40-video case around the internet at 500MB, not one to three gigabytes. What happens when you try to move a file around the internet from your ultrasound machine? It blocks up, your bandwidth cannot keep up with it, and your connectivity drops. You may have to resend it, which can take up time and cause delays in the interpretation and report. Ensure the machine you are purchasing can move a large set of videos across the internet readily. If its inherent workflow is poor, you will pay the price over time. So, what is that time and frustration worth to you? We deal with this every day in the telemedicine world, having to employ a technician to specifically work with clients on this issue from a variety of machines; therefore, we have created protocol standards to avoid these pitfalls on our end. I relate this to you to help avoid these frustrating tech and doctor sonographer time-consuming issues on your consumer sonographer side of the workflow equation. In sum, when buying an ultrasound machine (concepts apply to CT or DR system as well), what is the cost of missing a lesion? Think about what happens when you miss a lesion owing to not addressing the issues above and compromising your ability to image a complete cavity in your patient. The result is you risk not being correct on your first opinion. That does not bode well for you as a professional, for the facility where you work, or for your reputation as a clinical sonographer. Most of all, it does not bode well for the patient, which is the opposite outcome we desire with respect to the reason we all went into the veterinary profession in the first place. Eric Lindquist, DMV, DABVP, Cert. IVUSS completed his undergraduate degree in zoology at Humbolt State University, and his veterinary degree at the University of Bologna in Italy. Dr. Lindquist is a boarded American Board of Veterinary Practitioners in canine and feline and was also a three-time president for the International Veterinary Ultrasound Society. He founded SonoPath in 2007, which he expanded into multiple mobile sonography operations, leading a team of over 15 boarded specialists who provide Educational TeleconsultationTM services and lectures worldwide on clinical sonography. SonoPath headquarters and Veterinary Education Center is based in Andover, NJ. Reference Lindquist E, Lobetti R, McFadden D, et al. Abdominal ultrasound image quality is comparable among veterinary sonographers with varying levels of expertise for healthy canine and feline patients. Vet Radiol Ultrasound. Nov/Dec 2021; 62, 1-6. Digital, 705-710. https://pubmed.ncbi.nlm.nih.gov/34510634
