A detailed look at ultrasound and vision

Introduction The implementation of ultrasound has evolved considerably from when I started performing ultrasounds back in 1996 with a mechanical probe and the mental “imaginoscope” necessary to interpret images and respective pathology. But with today’s technology, there is a vast array of image quality advancements, workflows, techniques, and ultrasound machine competitive factors that play a role in any ultrasound implementation on any given patient. Moreover, in today’s world, ultrasound is extremely available in clinics compared to 1996, 2006 or even 2016. These days it seems everyone has a probe in hand with a wide array of abilities used for obtaining diagnostic image sets and an even more vast array of abilities for interpretation of the presentation. This variety of sonographer and specialist background behind the probe is nothing new and has been the case since the early inception of ultrasound in practice going back to the 1980s. The difference today is the hands on the probe have become significantly amplified with clinical sonography being an essential daily diagnostic tool to maintain and enhance quality of care in veterinary medicine. From an image acquisition and interpretive standpoint, we must consider the body type and conformation of the patient, as well as the sonographer’s innate and trained adaptive ability, machine quality and acoustic power, and clinical support to ensure a complete image set is obtained. The quality of the images obtained, for example, from a grade 2/6 body score cat or ferret to a 6/6 body score Rottweiler and everything in between, changes dramatically as do the sonographic techniques necessary to image them all well. We must equally consider the search for the right ultrasound machine for the practice, the right sonographer to train, and the appropriate instructional technique, which can seem endless whether addressing an abdominal sonogram, or cardiac, thyroid, eye, or orthopedic ultrasound. The consistently best results for your practice depend on your ability to thoroughly investigate key issues surrounding the ultrasound machine, those who drive it, and those who indirectly utilize it. Rapid selection of an ultrasound machine, or one given to you in a lab deal without thorough investigation, more often than not leads to suboptimal utilization and frustration in your clinical sonography curve and implementation. It may even result in machine quiescence in practice. Extended remix version An abridged version of this article appeared in the January 2023 issue of Veterinary Practice News. Pinpointing your practice What type of facility do we have? Do we work with mainly FAST scanning in our facility? Do we employ other limited point of care techniques? Do we just use the machine for guided centesis and wait for our mobile sonographer to perform a complete exam? Then, we must decide, what is a complete exam? Is it acceptable to not image the adrenals every time? Do we just avoid the gastrointestinal tract and pylorus if the patient has ingesta in the stomach? Do we save in still image format or in video? Is imaging the common bile duct a standard view or considered a specialist image? All of these factors play into the central theme of not missing a lesion, which is the ultimate objective. Recently, American College of Veterinary Radiology (ACVR) and European College of Veterinary Diagnostic Imaging (EVDI), the radiology specialty organizations in the United States and Europe respectively, published a consensus statement for the standardization of the abdominal ultrasound examination.1 Prior to that, to my knowledge, the only proposed standardized protocol presented in abstract or published format was that of the Sonographic Diagnostic Efficiency Protocol (SDEP) in 2019 at the EVDI Congress in Basel, Switzerland and published as an abstract in Veterinary Radiology & Ultrasound.2 The good news is the SDEP protocol contains inherently all the elements of the ACVR/EVDI standards, so there is good correlation between the two. Prior to these efforts however, no protocol had ever been established as a point of reference for a full abdominal sonogram. Therefore, each sonographer would approach the image acquisition differently and often incompletely without a standard to follow. This reality has been fundamentally detrimental to clinical sonography historically and even more damaging to the telemedicine process. These recent standardization efforts assist the veterinary ultrasound community in having a focused goal for each exam and should assist in the improvement of image sets going forward. The next step is to ensure the machine selection, education around the machine and sonographer, as well as the cultural factors leading up to the sonogram are optimized. We will examine all those factors in this article and make recommendations on how to optimize the sonographer’s ability to obtain a standardized image set in all patients. Ultrasound 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, as opposed to the human model with RDMS (registered diagnostic medical sonographer) trained sonographers who have semesters of higher learning on ultrasound physics, operational procedures, and image optimization. When was the last time you heard of a human being scanned by a radiologist or even a generalist? RDMS technicians image nearly everything under the probe in human medicine. Veterinarians and veterinary technicians do not have the two- to four-year training of an RDMS. This means maximization of machine capacity proactively by the manufacturer and distributor is essential to minimalize user error in veterinary medicine, as the vast majority of our sonographers have only a fraction of training compared to RDMS counterparts no matter what the title. Even radiologists train in ultrasound modality only as a part of their residency program that encompasses radiography, MRI, and CT, as well as other specialty imaging modalities. Therefore, since none of us are RDMS trained focusing on a two- to four-year program just with ultrasound image acquisition, we must shift the focus into a “what we need to know” simplification of the learning process, as well as proactively prepare the ultrasound machine for a point and shoot workflow as much as technically possible. As a career-long consumer clinical sonographer, I always recommend focusing on image resolution, contrast appearance, acoustic power, probe frequency for the body conformations you are dealing with in practice, efficient knobology flow, and processing speed. The price is the price regarding ultrasound machine quality, as ultrasound purchases remain a get-what-you-pay-for scenario, assuming pricing is categorized appropriately. This get “what you pay for” concept holds true despite recent trends and marketing angles that we see that may suggest otherwise, where point-of-care machines with weak acoustic power and base level resolution are often marketed as full body ultrasound units when they are designed for FAST scanning or small animal imaging. Just as the lower-end units improve their image quality, the higher-end units do as well and the bar of standard of care continues to evolve as does the level of ultrasound interpretation. The experienced interpreting general practitioner or specialist will recognize more subtle changes with improved machine quality and imaging techniques implemented. Just ask any clinical sonographer, with a career and business based upon obtaining the right consistent diagnostic result, how machine quality, company support, and eventual price play into that. Every ultrasound machine producer and every distributor has a personality behind the product. Ensure this personality fits with who you are as a practitioner, as you will have a better long-term (at least five years) experience with your newly purchased and implemented machine. Image optimization and avoiding pitfalls The following will examine how to optimize each of these preceding clinical sonography factors and, more importantly, how to avoid the pitfalls that an inadequate purchase decision can create. The culture of clinical sonography (ultrasound plus internal medicine plus surgical concepts) requires application of the ultrasound exam early in the clinical case. The “if it’s sick it needs a probe” concept does nothing more than stay ahead of the patient regarding its ultimate clinical destination whether surgical, medical, intensive care, oncological, or quality of life/hospice implementation. I would love to perform a multicentric study that would compare the last three months of sick patients that are admitted to any clinic that does not employ ultrasound on day one of presentation, calculate the time from clinical presentation to direct diagnostic outcome, and compare that time frame data set to a similar set from a clinic that employs an ultrasound with every sick patient on day one directly along with a general workup on the day of clinical presentation. A comparison of elapsed time from clinical presentation to definitive direction would be very illuminating. I already know the answer, as does every clinical sonographer in my circles. But since we are scientists at heart and culture, a retrospective study would be indicated to prove this premise, and I would love to collaborate with any facility that wishes to contribute data in this regard. Our job as clinicians initially is to define a patient’s therapeutic destination based on the clinical pathology at hand, whether it is a surgical case, a medical case with garden variety pancreatitis, a Cushing’s case, or a multicentric neoplasia to be defined by cytology or biopsy at the time of the sonogram. If there is no culture of “If it is sick, it needs a probe” then animals often sit and wait without a direction with global diagnostic testing alone, lacking specific diagnostics to help rule in and rule out direct underlying clinical pathology. For example, imagine the patient with an inflamed surgical gallbladder and/or common bile duct presenting clinically as “pancreatitis” and being treated as such. This is a common occurrence in our caseload as according to our studies only 25 percent of surgical biliary patients have visible icterus and about 50 percent will have elevated bilirubin.3 Therefore, if a clinical sonogram is not performed early in the workup of these patients, the treatment direction is fruitless and risks the life of the patient. I could list numerous examples of various presentations in this regard, but you get the idea. The root problem in any soft tissue pathology patient more often than not can be imaged and interpreted sonographically or have pathology ruled out with a complete negative scan. The value of a negative scan, ruling out most of our differential list, is truly underestimated and often a value that is not properly communicated to the pet owner. This clinical sonography approach of “if it’s sick it needs a probe” directly enables a bridge to the correct diagnostic and therapeutic direction, i.e., enhancing diagnostic efficiency. A diagnostically efficient clinical sonography exam is not only limited to the clinical sonographer’s imaging techniques, machine selection, and ability to interpret the image set in combination with the clinical exam and supportive lab work and radiographs. Diagnostic efficiency lies within the mentality of the clinician and facility culture that elects sonography early or later and plays a role in the early efficient and accurate outcome of every case. The same could be considered for computed tomography, which in combination with clinical sonography and supportive diagnostics is the most complete diagnostic effort to determine a definitive diagnosis in our ailing patients, in my experience. The combination of ultrasound and CT scan is a subject for future discussions. However, if you think about the common pathologies that are revealed under our on-site and virtual telemedicine ultrasound probe, you should wonder “what am I missing by not doing an ultrasound early at the moment of presentation?” These are some of the most common clinical histories we encounter in small animal medicine: The vomiting patient The lower urinary tract sign patient The PU/PD patient The respiratory distress patient The diarrhea patient The anorexic patient The weight loss patient All of these often have common straightforward findings on ultrasound or subtle findings that are technique and machine dependent, or possibly have no significant finding at all. Therefore, post sonogram the patient moves next to surgery, intensive care, out-patient medicine, oncology/hospice, directed to additional modality such as CT, or back home happy with the owner with no significant finding viscerally. If we choose to investigate further after a negative sonogram with a persistently clinical patient, then we can pivot clinically to other modalities (CT, MRI, full CNS exam, metabolic and special testing) to find the CNS, orthopedic or metabolic pathology that may be in play making the patient be “just not himself.” But we can only go there if we have a negative sonogram that tells us the problem is not structurally visceral. The negative sonogram is just as important as the positive one, as the negative sonogram rules out all the prior visceral pathologies considered and drives us to diagnosing other disease such as pain related spinal disease-causing anorexia as opposed to pancreatitis or visceral disease causing a tense abdomen. Moreover, a probe on a heart positioned properly, or at times even as a targeted point of care technique of left ventricle and left atrium, can rapidly tell us if the respiratory distress is left cardiac failure related or not. If it is not cardiac related then you know the diagnostics are based on clinical and respiratory clinical signs combined with radiographic findings, CT, bronchoscopy and so forth. Clinical sonography is our diagnostic bridge to cross in our workup. Therefore, the factors that lead to success across this bridge cannot be taken lightly and range from the economics of purchasing the right machine and education to the culture behind and around the probe in your local and referring veterinary community. An important clinical, ethical, and financial bridge to cross in every case Ultrasound/clinical sonography is a bridge to one of four doors of outcome or direction for any patient, which is why living by a probe for any sick patient is essential. The greater diagnostic time employed with our clinical patients the greater detriment will follow with our clinical outcomes as well as the economic and emotional output from the pet owner, which unfortunately often defines a pet’s finality when the pet owner has exhausted his/her economic and emotional resources. This unfortunate inefficient cascade also plays a large role in our psyche as veterinarians because we feel we could have done better for that pet and the pet owner. Just look at the extremely elevated costs to the pet owner for veterinary workups and treatments compared to the 1990s and early 2000s. We, as practitioners, can thwart this issue by making more efficient clinical decisions rendering economics behind the pet more reasonable and able to treat what we find early, preferably within 12-24 hours of presentation. Clinical sonography performed well at first presentation is a big part of that 12-24 hour rule we operate by in my circles. Without that clinical sonographic bridge, we are left trying to find another way across the river for the right direction of the case. If I had my preference in an ideal scenario, knowing what I know now after 25 years of clinical sonography as opposed to what I knew coming out of college, or a few years out of college, I would put a probe and run a CT on every sick patient and fill in the blanks with CBC, Chem, UA +/- radiographs and special testing. Moreover, I would efficiently package the testing to make it economically feasible for most pet owners that bring their sick patients through our doors. In that scenario the sensitivity of CT and ultrasound will already give solid direction to be further interpreted and refined by the other tests being run. I’m sure I will get feedback for this, but it really is about time someone related what we are living daily from an imaging standpoint. We need to get answers for our patients and pet owners that are as efficient and accurate as possible to limit patient suffering, enhance the early diagnosis so the patient has a proactively better body state to respond to therapy, and to limit enduring financial costs in our workups while enhancing the diagnostic accuracy of the workup. If we decline to progress in the efficient “if its sick it needs a probe” option that we have in 2023—which did not exist in veterinary school as recently as five to 10 years ago, let alone 35-40 years ago when ultrasound essentially started in veterinary medicine—then we are limiting our ability to practice our profession in the fashion we envisioned as veterinarians. Moreover, in not taking advantage of more efficient diagnostic workflows available today, we risk compromising our art of veterinary medicine, our personal and professional time, the patient’s quality of life, and the pet owner’s emotional and financial well-being; all of which plays into the cost of missing the lesions we encounter clinically. Utilizing “if it’s sick it needs a probe +/- CT” will help achieve those goals that we originally set out to accomplish when we applied to vet school and as we face the overwhelming and disheartening front-line veterinary economic challenges in 2023. All of this plays into the selection of an ultrasound machine or any capital equipment since the best sword is only as effective as the hand that wields it and the culture behind the training of the swordsman. Key takeaway to remember Overwhelmed by this conversation? Maybe you were just thinking “I need to buy an ultrasound machine for my practice” and weren’t expecting all these functional factors to consider. If you take anything from this article, just remember clinical sonography is not about buying an ultrasound machine at the lowest cost you can and placing it in the facility and expecting the novice to even seasoned sonographer to maximize its ability to not miss a lesion. Clinical sonography is about setting up a daily educational and support infrastructure around the right ultrasound machine, improving your image set daily so you don’t endure the cost of missing a lesion while enhancing your sonographer’s and facility’s image footprint. The images on your report are interrogated by colleagues in house, in your community, and even worldwide these days; your image set and the case report, represent your clinical sonography calling card. Maximizing the image quality is a core part of marketing your ultrasound service and the seriousness around it. Non-optimized images project poor seriousness of process. Optimized images project deliberation and professionalism of process that reflects who you and your facility are as an entity. This is true for ultrasound as it is for radiographs, CT, MRI, or any imaging modality or even report graphics and layout produced in your facility. Essentially, for these reasons, your inherent costs involved in capital equipment purchase and operations should derive partially from your marketing budget that should be fostering the mentality of clinical sonography and “if its sick it needs a probe” throughout your facility and client base. PART TWO COMING SOON Part 2 will address all the common and not so common pitfalls regarding ultrasound machine selection, education, technological workflow, and veterinary culture influences 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. 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 threetime 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 Teleconsultation services and lectures worldwide on clinical sonography. SonoPath headquarters and Veterinary Education Center is based in Andover, NJ. References 1. Seiler GS, Cohen EB, d’Anjou M-A, et.al. ACVR and ECVDI Consensus statement for the Standardization of the Abdominal Ultrasound Examination. Vet Radiol Ultrasound. 2022;1-14. 2. Lindquist E, Lobetti R, McFadden D. Proposed standardized procedure for abdominal sonograms in dogs and cats: Sonographic Diagnostic Efficiency Protocol (SDEP®). Abstract presented at EVDI Congress 2019; August 21-24; Basel, Switzerland. Abstract published Vet Radiol Ultrasound. 2019 Nov. 3. Lindquist E, Brown A, Frank J, Bush J. Clinical Parameters in Dogs with Sonographically Diagnosed Surgical Biliary Disease. ECVIM, Porto, Portugal Sept 8-10, 2009

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A detailed look at ultrasound and vision – Part 1

Part one covers recent advancements, specialty considerations, and the need for standardization

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